HomeMy WebLinkAboutPermit Sidewalk 2019-05-03Driveway/Sidewal k Perm it Appl ication
lcity Springfield
Appiication Date:
Permit Number
Issue Date:
225 Filth Street, 5pringfield, Orcgon 97 477
Transportation & Engineering Section, Public Worla Department
Phone: 541 726-3753
SPRINGFIELD
OR,EGON
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Applicant:
Address:
City:
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Tax Lot
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Subdivision
Owner:
Address:
C)ty:
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Fees
@50.1 1 5F
X 565 2nd Cut
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REQUESTED PERMITS:
ffgldewaik Amount of sidewalk in excess of 90 feet
p Sidewalk Renat )<'L-
E CurbCuVDriveway: NumberofDriveways_
6Multiple Permit Discount each: (Maximum 2)t lvlulti permit discount good for one site and one site inspection only
appiies to 2nd and 3rd permits oniy. Not sidewalk repairs
{ s%Technologyfee
II Proof of lnsurance: 5500,000 Minimum if work is done by property owner.
l- Facility Meets 201 1 PROWAG For ADA Compliance
s12 r.00
522.0O
X 51 21.00 1 st Cut
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Total due with permit 5
CONTRACTOR'S INFORMATION
Name: (4ltJtC /c,ltq at + CcarsrZu<A rnt Phonet fQt 68e ??33
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Address:
City:
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Fuq elr€state: o{z ZtP: q?+4,
/6e{?Z Expiration date:Contractor Registration #
Project Supervisor C"(n/C D€,rtY Phooe: J71 gt; t779
INSPECTIONS:
An inspection request should be made prior to pouring concrete, after the proposed work has been formed and made ready to pour.
Curbcutandsidewalkinspectionscall:541 726-3769(recording)StateyourdesignatedCityjobnumber/permitnumber,jobaddress,
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. Inspections are to be
called in after excavations are made and form work is in place, but prior to pouring concrete.
are to Utilities Coordinating r5 digging.
SIGNATURE:
Amount Received:Date Paid:
Received By:Receipt No.
By signature, i state and agree that I have carefully examined the completed application and do here by certifo that all 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
Springfield 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 requlred 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
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set of pra ns wil I "^^';w-es du ri ns construction'
Date: f- 3 -( ? -
SITE INFORMATION
Location of Work: