HomeMy WebLinkAboutPermit Encroachment 2019-08-08Form
Application to Work in the Right of Way
Once the applicotion has been approved, a permit will be issued
City ofSpringfield
can to
wlll need to come to Publlc Works, Clty Hall to proclss permlt.
will need to complete applacation, save as, then attach to
il or print and bring to Publi< Works City Hall.
225 Fifth Street
Springfi eld, Oregon 97 477
Engineering &Transportation Services Division
Phone (541) 726-3753
Step 1-Location of Work
Who is filling out the application?
ln this section, you will need to identiry the Applicant, Owner of the abutting property, and the Contractor, if applicable.
Example:
John Doe is the owner ofthe abutting property. You would need to put name, address and contact information.
Jane Doe is the Applicant. This is the person filling out the application and filing for a permit. You would put in the contact information.
Utility Doe is the utility company that is doing work in the right of way and would be an considered an applicant. You would put in the
contact person's information.
Contractor Doe is the contractor who will be doing the work in the right of way. You will need to put this contact and license information.
SiteAddressorLocation: 17o -1 fl 1f .
Applicant: -?aD
Email Address: T+De*e<.-eurE.ll,.-f LY ,e a+
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Tax Lot
enone: 5{ I .3{9, t9l
tvUlOwner:
Address:
City:
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Phone:
Phone:
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Contractor:
Contractors
Project Supervisor:
lnsurance
Registration (CCB) #:{t
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Expiration Date:
Phone:
Z/t.t /zo
f- Proof of lnsurance, minimum 5500,000 coverage limit
Utilities
Does your utility company have a franchise ogreement or license with the City?
Please identifo which type of agreement you currently have with the City. f Franchise Agreement f License
Name of other utilities if this is a joint project :
lntent of project for other utility who will
own any facilities placed in right of way:
Step 2: Description of Project
What type of work do vou need to do?
ln this section you will describe the location, intended use, and what measures you are implementing, such as traffic control
measures, dust control measures, and types of backfill material to be used.
-Provide the start and end dates, stan time of day and end time of day, of your project. lt is imponant that you give
time of day that you are requesting for your project work. There are codes and inspections that are time sensitive.
-ldentify your method of intrusion into the surface of the right of way, such as cut, bore, or drilling.
-Describe the surface area length, width, depth, and height of your project.
-ldentiry what type of surface material is currently there, what you will do with this material, what is the replacement type
of surface material you will use, and what type of backfill material you will be using.
-Any required separation from other facilities.
lltacing new facilities in the right of wa V ? e ,
l- Repairing/maintaining existing facilities
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Project
Description:
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Print Form
Period of use or time of construction: 7am to 6 om only, unless it's an emergency.
From Date:To Date:
Daily Start Time:Daily End Time:
5TQE nruwerlhese questions next
Are you working in the right of way or connecting to City facility? lf yes, continue at Step 2a: Work Site Area
Are you storing material/objects in the right of way other than during hours of work? lf yes, continue at Step
3: Submit a Work Plan NO
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f
Step 2a: Work Site Area
l- Cut l- Bore Other:
Length Depth
Existing Surface Material:
width Height
5urface replacement material to be utilized:
Backfill material to be utilized
System Connections to City lnfrastructure
Directions: Submit plans that identify in detail the scope of work to be performed in the City right of way/easement. The work shall be
performed by a licensed contractor that is aware of wastewater spills/overflow reporting requirements and City design standards. Your
permit shall have specific instructions from the City inspector on how to perform the work. Keep these instructions on site.
t' wastewater connection
[- To Stub
[\Main Line
[- Other:
Description:
[- Stormwater Connection
T Catch Basin/Bubbler
[- Stub
[- Main Line
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Safety and Environment Vou are requirea to catL ffre Lane Utitities Cooraindtlnq C Call l.lumbe/
81 1 or 1-800-332-2344
Air Oualitv
Type of Dust Control to be utilized:
48 hours before digging.
Stormwater Pollution Prevention
Directions: The City is required by Federal and State law to monitor the discharge of construction stormwater and site runoff. Applicants
shall develop and submit a Stormwater Pollution Prevention Plan (SWPPP) that minimizes to the maximum extent practicable the
discharge of sediment and other pollutants to the public stormwater system. Call LDAP with questions, 5.a1 / )6 5489.
Listed below are some of the most common issues on right of way construction projects. How will you address these items on your
SWPPP? Please be aware that each project is unique and may present challenges not addressed in this set of examples.
T Dewatering l- Soil Erosion l- Hazardous material storage/spill prevention
f Sawcut slurry runoff [- Site runoff/sedimentation
Wastewater Soill/Overflow Prevention
Directions: City policy requires that all work performed in the City right of wayleasement is in full compliance with DEQ and EPA
regulations. No spillage of raw sewage shall occur during construction, including spillage in an open trench or excavation. The contractor
shalltakeall reasonableprecautiontoavoidspillsandshall immediatelynotifyCityof SpringfieldMaintenance54l 726 3615 or
541 7?637b1: A{ter lrcLrrrlriierclencyResl:o,r:e le.r'r5.11 951 3428inthe eventof aspill.
Plan submittal for Wastewater main line work
f Bypass pumping l-- Temporary plugging of sanitary main
Traffic Control Plan Criteria for Citv of Sprinofield Traffic Control Plan Submittals
Directions: You will need to submit a Traffic Control Plan, which will need to be in compliance with the Manual on Uniform
Traffic Control Devices (MUTCD) and Oregon TemporaryTraffic Control Handbook.
Plan Submittal requirements:
Submit your Traffic Control Plan (tCP) with the following information on 8.5"x1 1" or 1 1 "xl 7" paper. Fill out and submit this form with
your TCP.
Page 2 of 3
The TCP shall be a legible hand drawing, or a computer aided design with the following information:
Traffic Control Plan form is located at www.springfield-or.gov/menuonlineforms
A vicinity map:
That includes the north arrow, road names, intersection/driveway access points, curb lines, the work zone, and any special features such
as buildings, access points, sight obstructions, that could affect the TCP.
Location:
Where will the TCP be active? This can be a line drawing of the work zone(s) and/or a map that clearly indicates where traffic control
devices will be placed, including spacing and cone tapers.
Attachments of the appropriate traffic control diagram(s) as shown in the current MUTCD and/or the ODOT Oregon Temporary Traffic
Control Handbook that reflect the work zone may be included as a standard reference. oDOT's Traffic Control Handbook website: \rylvw.
oregon.gov/ODOT/HWY/TRAFFIC-ROADWAY/docs/pdf/OTTCH 06,pdf?9a=t
[- Traffic Control Plan attached in email to Land Development; LDS@springfield-or.gov
- No Traffic Control PlanI Th"r".r" no public traffic safety issues with this application.
Step 3
What kind of work olan do you need?
You will neTd to submit a copy of the work plan, which includes:
--6ite location and vicinity map - ldentify extent of excavationsI iDclude North arrow. ' or bore locations.
--16utline limits of disturbance/y
of *ort ir"r- Show location of utilities within right of way. ldentiry pipe
T identiry staging/material f size and type' mainline connection location' and
srorage areas connection tYPe'
Work Plans attached in an emailto Land Development; send to LDSi4springfield-or.gov. Reference site location and name in subject line.
*Construction of ADA ramps or other ADA facilities require submittal of detailed topographic survey and design sheets stamped
by a Professional Engineer licensed in the State of Oregon. Design of ADA facilities shall at a minimum meet the current federal
Technical Requirements as described in the United States Access Board's 2011 Proposed Accessibility Guidelines for Pedestrian
Facilities in the Public Right-of-way Notice of Proposed Rulemaking (NPRM).
lnformation
Fee
Encroachment/Placement Permit 5345.00
Fees that may apply
-A 5% Technology Fee will be applied to the total cost ofthe permit for processing the application.
-A 51061.00 Asphalt deposit is required when the asphalt will be disturbed.
-Additional financial security may be required.
Deposits and Financial Security
Projects involving work within public right of way in the City of Springfield are subject to deposits or other approved forms
offinancial securitythatmayincludeperformancebonds,set-asideletters,orirrevocablelettersof credit. Thetypeof
financial security is determined by the project's size, scope, and potential impact to public infrastructure. Examples of typical
impacts that will require financial security include asphalt trench cuts and sewer repairs that involve cuts to a main line.
Warranties
Financial security is held by the City during a warranty period that typically lasts one year and begins when the project
passes final construction inspection. The warranty period allows the City to monitor the structural integrity of repairs and
determine their long-term viability. Financial security provides the City with the means to repair infrastructure should
failures that remain uncorrected by the applicant or applicant's representative occur during the warranty period. A final
warranty inspection will be conducted eleven months after the final construction inspection. Financial security will be
released when the warranty period has passed final inspection.
Restoration of City facilities
It will be determined by the Public Works Director at the time of the I I month inspection as required in Municipal
Code 3.222 that the work area in the public right-of-way is in as good a condition or better than it was before the
issuance of the encroachment permit. . Municipal Code 3.210 (2).
When do you need an Encroachment permit?
Municipal code 3.208 Work On or Under Surface-Encroachment Permit Required (h{plwvry,qclde.llslcodes/sprinqfield/)
defines when you need an encroachment permit.
When do you need a Placement permit?
Municioal code 3.224 Placement of Devices or Structures in the Public Wav ( htto://M.qcq,de.uveorleslslringfieldl defines
when you need a placement permit.
Step 5: Signature
Date:6 I IbSignature
Check one:l-- Owner [- Applicant
You are required to rail: The Lane
(aon*".o, T UtilityPqectManager
Utfities Coordinating Coun(il s 'One Ca[ Numbei l-8OO 332.2344,
48 hours before before digging.
Page 3 of 3
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