HomeMy WebLinkAboutPermit Sidewalk 2019-06-24Driveway/Sidewalk Permit Appl ication
City ofSpringfield
Apprication o
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Transportation & Engineering Section, Public Work Department
Phone: 541 726-3753
lssue Date:
SITE INFORMATION
Location of Worlc fr/
Applicant:
Address:
City:
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Tax Lot
Subdivision
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Address:
City:
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REQUESTED PERMITS:
Amount of sidewalk in excess of 90 feet
Repair
fa Curb CuUDriveway: Number of Driveways_
f 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
!y' 5%Technologyfee
f Proof of lnsurance: 5500,000 Minimum if work is done by property owner.
Fees
1 2 t.00 @50.11 SF
51 21 .00 1 st Cut X 565 2nd Cut
Total due with permit S
7a
f Facility Meets 201 I PROWAG For ADA Compiiance
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CONTRACTOR'S INFORMATION
Name:
Address:
City:State:zlP..
Contractor Registration #
Project Supervisor
Expintion 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 kecording) 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:OO 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 priorto pouring concrete.
SIGNATURE:
Amount Received:
Receipt No.
By signature, I state
Date Paid:
Received By:
'examined the completed application and do here by certify that all information hereinand agree that I have carefully
performed shall be done in accordance with the Ordinances of the City ofis true and correct, and I further certiry that any and all work
Springfield app licable City Standard specifications and drawings and the laws of the State of Oregon pertaining to the work described
herein, I further certify that only contErctors 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 perm ittee 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.
1 -800-332-2344,beforeUtilitiesareto
Signature Date:
Permit Number
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