HomeMy WebLinkAboutPermit Sidewalk 2019-08-14Driveway/Sidewalk Perm it Appl ication
City of Springfield
Application Date:
Permit Number
lssue Date:
225 Fifth Street, Springfi eld, Oregon 97 477
Transportation & Engineering Section, Public Works Department
Phone: 541 726-3753
SITE INFORMATION
Location of Work:
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Applicant:
Address:
City:
Phone:
Tax Map
Tax Lot
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State:ZIP:
Subdivision
Owner:
Address:
City:
Phone:
State:ZIP:
REQUESTED PERMITS:
f Sidewalk Amountofsidewalkinexcessof90feet
..1-.S'if,ewalk Repair
/' f- Curb CuvDriveway: Number of Driveways-
[- Muhiple Permit Discount each: (Maximum 2)
Multi permit discount good for one site and one site inspection only
applies to 2nd and 3rd permits only. Not sidewalk repairs
[p&Technologyfee
[- Proof of lnsurance: 5500,000 Minimum if work is done by property owner
T Facility Meets 201 1 PROWAG For ADA Compliance
Fees
@s0.12 sF
1 st Cut X 567 2nd Cut
Total due with permit 5
s 1 25.00
CONTRACTOR'5 INFORMATION
Name:
Address:
City:
Phone:
State:ZIP:
Contractor Registration #
Project Supervisor
Expiration date:
Phone:
INSPECTIONS:
An inspection request should be made prior to pouring concrete, after the proposed work has been formed and made ready to pour.
Curb cut and sidewalk inspections call: 541 726-3769 (recording) State your designated City job number/permit number, job address,
type of inspection requested, and when you will be ready for inspection, Contractor's or Owner's name, and phone number. Requests
received before 7:00 am will be made the same day, requests after 7:00 am will be made the next working day. lnspections are to be
called in after excavations are made and form work is in place, but prior to polrr ing con(rete.
You are required to c -l
SIGNATURE:
Amount Received:
Receipt No.
Date Paid:
Received By:
By signature, I state and agree that I have carefully examined the completed application and do here by certify that all information herein
is true and correct, and I further certify that any and all work performed shall be done in accordance with the Ordinances ofthe City of
Springfield applicable City Standard specifications and drawings and the laws of the State of Oregon pertaining to the work described
herein, l further certify that only contractors and employees who are in compliance with ORS 701 .055 will be used.
The City may inspect the work site described in this permit at any time during a one year period following receipt by the City of notice of
completion of the described work and specify, at the City's sole discretion, any additional restoration work required to return the site to a
standard acceptable to the City. The permittee will be notified in writing of any work required and will have thirty days (30) from the date
of the notice to complete the work not completed at the end of the thirty days will be performed by the City and the costs will be billed
to the permittee.
I further agree to ensure that all required inspections are requested at the proper time that project address is readable from the street and
the approved set of plans will remain on the site at all times during construction.
,Signature Date:3/rr,