HomeMy WebLinkAboutPermit Sidewalk 2019-08-27Driveway/Sidewalk Permit Application
City of Sptingfield
Application Date:
Permit Number
lssue Date:
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225 Fifth Street, Springfield, Oregon97477
Transportation & Engineering Section, Public Works Department
Phone: 541 726-3753
SITE INFORMATION
Location of Work:
Applicant:
Address:
City:
J.
Phone:
Tax Map
Tax Lot
54t '32( 'W
State:ztP: q] q7I
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Subdivision
Owner:
Address:
City:
Phone:
Fees
State:ZIP:
REQUESTED PERMITS:
l- Sidewalk Amountofsidewalkinexcessof90feet
l- Sidewalk Repair
(Curb Cut/Driveway: Number of Driveways _
T 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
ft,5olo Technology fee
f- Proof of lnsurance: 5500,000 Minimum if work is done by property owner,
[- Facility Meets 201 1 PROWAG For ADA Compliance
@50.12 SF
S125.00 lstCut X 567 2nd Cut
s 1 25.00
523.00
542
Total due with permit 5 14,"(
CONTRACTOR'S I NFORMATION
Name:
Address:
City:V-';C49*9,
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SuiT€ tOL- 2b{
State:ZIP:
Contractor Registration #
Project Supervisor
LZU 03I Expiration 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 (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. R€quests
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 1o poLll ing con( rete.
are required to call: The Lane Utilities Coordinating Council's "One Call Number" 1-800-332'2344 4s I'ours $6re beiore diggrng
SIGNATURE:
Amount Received:
Receipt No.
Date Paid:
Received By:
By signature, I state and agree that I have carefully examined the completed application and do here by certify that all information herein
istrue and correct, and I further certify 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
(ompletion of the described work and specify, at the City's sole discretion, any additional restoration work required to return the site to a
standard acceptable to the City. The permittee will be notified in writing of any work required and will have thiny 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
Signature
will remain on the site at all times
Date: