HomeMy WebLinkAboutPermit Sidewalk 2019-03-10Driveway/Sidewa I k Permit Application
Oty of Springfield
Application Date:
Permit Number
lssue Oate:
63- \q- l1 225 Fifth Street, Springfield, Oregon 97477
Transportation & Engineering Section, Public Work Department
Phone: 541 726-3753
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SITE INFORMATION
Location of Work:
Applicant:
Address:
City:
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zr'Llt statet 0(L ztP:41q 1
\)Phone:
Tax Map
Tax Lot
Subdivision
Ownen
Address:
C)ty:
Phone:
State:ZIP:
REQUESTED PERMITS:
lI Sidewalk Amount of sidewalk in excess of 90 feet
ffi SidewalkRepair X1-
[- CurbCuVDriveway: NumberofDriveways_
T Multiple Permit Discount each: (Maximum 2)
lvlulti permit discount good for one site and one site inspection only
applies to 2nd and 3rd permits only. Not sidewalk repairs
.$% Iechnology fee
l- Proof of lnsurance: 5500,000 Minimum if work is done by property owner.
T Facility Meets 201 1 PROWAG For ADA Compliance
Fees
121 .00 @50.1 1 sF
s22.00
S121.00 lstCut X 565 2nd Cut
S41
Total due with permit 5 4b-aD
CONTRACTOR'S INFORMATION
Name: Arn ehon",(s.ril 5r1 1{5-
Address:
City:\F)
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State: o(? Zt?: 4'jr.l1i
Contractor Registration #
Project Supervisor
lg3s \g Expiration date:
Phone:
IN5PECTIONS:
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 pouring concrete.
are required to ca 48 dig9in9.
SIGNATURE
Amount Received:
Receipt No.
Date Paid:
8y signature, I state and agree that I have carefully examined the completed application and do here by certifu that ail information herein
is true and correct, and I further certiry that any and all work performed shall be done in accordance with the Ordinances ofthe City of
5pringfield applicable City Standard specifications and drawings and the laws of the State 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 specifo, 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 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.
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Received By: .?pl*puA1
Signature *Date:7-rc-g