HomeMy WebLinkAboutPermit Sidewalk 2019-03-28Driveway/Sidewa I k Perm it Appl ication
Cityof Springfield
Application Date:
Permit Number
lssue Date:
225 Fifth Street, Springfieid, Oregon 97477
Transportation & Engineering Section, Public Work Department
Phone: 541 726-3753
OREGON
SITE INFORMATION
Location of Work:
Appiicant:
Address:
City:
enon",@q
State:ZIP:
Tax Map
Tax Lot
Subdivision
Owner:
Address:
City:
Phone:
State:ZIP..
REQUESTED PERMITS:
l- Sidewalk Amountofsidewalkinexcessof90feet
fi Sidewalk Renair
l- Curb CuUDriveway: Number of Driveways_
E Muitiple Permit Discount each: (Maximum 2)
ivluiti permit discount good for one site and one site inspection only
applies to 2nd and 3rd permits only. Not sidewalk repairs
f: 5% Technology fee
f Proof of lnsurance: S500,00O Minimum if work is done by property owner.
f Facility Meets 201 1 PROWAG For ADA Compliance
Fees
121.00 @50.1 1 SF
5121.00 lstCut X565 2ndCut
Total due with permit 5
CONTRACTOR'S
Name:
Address:
City:04 zte(
,n""", Wlqrl$ffif
Contractor Registration #
Pro.ject Supervisor
Expiration date:
Phone:
INSPEC]'IONS:
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 lecording) State your designated City job number/permit number, job address,
typeofinspectionrequested,andwhenyouwillbereadyforinspection,Contractor'sorOwner'sname,andphonenumber. 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 pouring concrete.
are to call:Lane "One Ca
,]r5
SIGNATURE:
Amount Received:Date Paid:
Receipt No.Received By:
By signature, I state and agree that I have carefully examined the completed application and do here by certi! that all information herein
iitrue and correct, and I further certiry that any and all work performed shall be done in accordance with the Ordinances ofthe City of
Sprinqfieid applicable City Standard specifications and drawings and the laws of the 5tate of Oregon pertaining to the work described
herein, I 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 retum 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 alt required inspections are requested at the proper time that project address is readable from the street and
the approved set of pla
Signature
ns will remain on the site at al
o^,", 3-e8-adll