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Home My WebLink AboutPermit Sidewalk 2019-08-30Driveway /Sidewalk Permit Application of Springfield Application Date: Permit Number lssue Date: Sl,Rli.lGSlgLD225 Ftflh Street, Springfield, Oregon 97477 Transportation & Engineering Section, Public Works Department Phone: 541 726-3753 OR€6Or{ SITE INFORMATION Location of Work: Easterly terminus of 'A' Street (cul-de-sac) between 14th & 16th Streets Applicant: Bob Tate nrrone: ls+1-914-9918 P.O.Box26423Address City:Eugene state: oR zlP: 97,402 Tax Map 17-03-36-31 Tax Lot 4700 n/a (Land Partition pending; see Case No. 81 1-19-000034-fYP2)Subdivision Owner: Address: City: Jean Tate 1 375 Olive Street #51 0 Phone:541-687-1457 state: oR zlP: 97,401 REQUESTED PERMITS: X Sidewalk Amount of sidewalk in excess of 90 feet [* Sidewalk Repair lf, Curb Cut/Driveway: Number of Driveways 1 lX Multiple 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 X sohTechnology fee f{ Proof of lnsurance: 5500,000 Minimum if work is done by property owner ffi Facility Meets 201 'l PROWAG For ADA Compliance @s0.11 5F S 1 21 .00 'l st Cut X 565 2nd Cut Fees s121.00 s22.00 $+t Total due with permit S CONTRACTOR'S INFORMATION Name Dynasty Concrete Co. (Contact: Bob Tate)Phone: 541-914-9918 Address P.O.Box26423 City:Eugene Contractor Registration Project Supervisor state: oR zlP: 97,402 Oregon CCB License #187590 Expiration date 2019-07-31 Phone: qq f 5S'{ - 150t INSPECTIONS: An inspection request should be made prior to pouri ng concrete, after the proposed work has been formed and made ready to pourCurb cut and sidewalk inspections call: 541 726-3769 (recording) State your designated City job number/1 permit number, job address,type of inspection requested, and when you will be ready for inspection, Contractor's or Owner,s name, a nd phone number. Requestsreceived before 7:00 am will be made the same day, requests after 7:00 am will be made the next workin g day. lnspections are to becalled in after excavations are made and form work is in place, O" You are required to call The Lane Utilities Cooid inating Council's "One Call Number"l-A00J 48 hours before before digging32-2344, SIGNATURE: Amount Received: Receipt No. By signature. I state and agree that I have carefully yan Date Paid: Received By: 'examined the comp d all work performedis true and correct, and I further certify that an leted application and do here by certify that all information herein shall be done in accordance with the Ordinances of the Ci ty ofSpringfield applicable City Standard specifi cations and drawings and the laws of the State of Oregon pertaining to the work desc ribedherein, I further certify that only contracto rs and employees who are in compliance with ORS 701.055 will be used.The City may inspect the work site descri bed in this permit at any time during a one year period followi ng receipt by the City of notice ofcompletion of the described work and s pecify, at the City's sole discretion, any additional restoration work required to return the site to astandard acceptable to the City. The permittee will be notified in writing of any work required and will have thirty days (30) from rhe dateof 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 billedto 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 andthe approved set of plans will remain on the site at all times during construction. Signature Date: I CERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATE IS ISSUED AS A MAfiER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.,THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. COVERAGES CERTIFICATE NUMBER:REVISION NUMBER: DATE (MMIDD/YYYY) 812912019 IMPORTANT: lf the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. lf SUBROGATION lS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DUSTIN SAIN fil. u.,, s41-334-7707fI8.nnt . .,u' 541 -334-77OO NAIC #INSURER(S) AFFORDING COVERAGE TNSURER A : COUNTRY Mutual lnsurance Company 20990 PROOUCER DUSTIN SAIN (07589) 711 COUNTRY CLUB RD STE 203 EUGENE, OR 97401-0000 INSURER B: INSURER C : INSURER D : INSURER E : INSURER F : rNsuRED 7359296 DYNASTY CONCRETE CO PO 8OX24124 EUGENE, OR 97402 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSRITR TYPE OF INSURANCE INSR WN POLICY NUMBER POLICY EXP TMM'NNIYYYYI LIMITS A GENERAL LIABILITY GENERAL LIABILITY CLAIMS.MADE OCCUR LIMIT APPLIES PER: POLICY LOC A89236698 7131t2019 7t31t2020 EACH OCCURRENCE $ 1.000.000 DAMAGE TO RENTED PRFiTISFS /Fe mcrrrencel s "too ooo MED EXP (Any one person)s 5,000 PERSONAL & AOV INJURY s 1.000.000 GENERAL AGGREGATE s 2 000 000 PRODUCTS . COMP/OP AGG s 2.000.000 D A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS SCHEDULEO AUTOS NON-OWNED AUTOS A89236698 713112019 7t3112020 s 1.000.OO0 BODILY INJURY (Per person)c BODILY INJURY (Per accident)$ $ $ A r'UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS.MADE AU9241728 7t31t2019 7t3',12020 EACH OCCURRENCE s 3,000,000 AGGREGATE $ 3.000.000 DED RETENTION $ 'I O.OOO $ WORKERS COMPENSATION AND EMPLOYERS' LIABIUTY ANY PROPRIETOfu PARTNERYEXECUTIVE OFFICERYMEMBER EXCLUOED? (Mandatory ln NH) lf yes, describe under DEscRlPTloN OF OPERATIONS below N'A I WCSTATU. I I Tnav r rMrrs I OTH- FR E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE . POLICY LIMIT $ DESCRIpTtONOFOPERATIONS/LOCATIONS/VEHICLES (AttachACORDlOl,AddltionalRsmarksschedule,lfmorespaceisrequifed) JOB NAME: 170 16TH STREET SPRINGFIELD OR CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIPATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. )*nAUTHORIZED REPRESENTATIVE CITY OF SPRINGFIELD 225 FIFTH STREET SPRINGFIELD,OR 97477 I @ 1 988-201 0 ACORD 25 (2010/05)The ACORD name and logo are registered marks of ACORD AII rights reserved. Y'Ntl AtL 10 67 08 11 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTTCE OF CANCELLATTON TO CERTTFTCATE HOLDER(S) This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE PART COMMERCIAL AUTO COVERAGE PART COMMERCIAL GENERAL LIABILITY COVERAGE PART COMMERCIAL INLAND MARINE COVERAGE PART COMMERCIAL PROPERTY COVERAGE PART OWNERS AND CONTRACTORS PROTECTIVE LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART RAILROAD PROTECTIVE LIABILIry COVERAGE PART COMMERCIAL LIABILITY UMBRELLA COVERAGE PART WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY With respect to coverage provided by this endorsement, the provisions of the Coverage Part (Policy) apply unless modified by the endorsement. Cancellation The following is added unler the Cancellation Condi- tion applicadle to the Co'verage Parts (Policy) listed above: lf we cancel this policy for any reason other than non payment of premium, we will mail written notice of cancellation to the certificate holde(s) on file with the Company. Notice will be provided prior to the effec- tive date of cancellation. We will give the number of days notice as provided for in the Cancellation Condi- tion of this policy. The notice will state the effective date of cancellation. The policy period will end on that date. lf you cancel this policy, or if we cancel for non pay- ment of premium, we will mail written notice of such cancellation to the certificate holder(s) on file with the Company. The notice will state the date the policy was cancelled. The notice will be mailed by first-class mail to the last known mailing address of the certificate holder(s) on file with the Company. Any notice of cancellation provided by this endorse- ment applies only to the certificate holde(s) with a certificate of insurance applicable to this policy's period. Our failure to send notice of cancellation to the certifi- cate holder(s) will not amend, extend or alter the terms and conditions of this policy, including the can- cellation of this policy. lf there is a conflict between any other policy cancella- tion provisions pertaining to the certificate holder(s) and this endorsement, the other policy provisions shall control. Nothing contained here varies, alters, or extends any provisions of the policy except as provided in this endorsement. lnctudes copyrighted material of tnsurance Services Office, lnc., with its permission. Includes copyrighted material of American Association of Insurance Services, lnc., with its permission. Contains copyrighted materiat of the National Council on Gompensation lnsurance, with its permission. ail {n 67 0R ,l ,l Daaa 4 aI 4