Loading...
HomeMy WebLinkAboutPermit Encroachment 2019-07-01Reset Form l I Print Form 225 Fifth Street This application can be emailed to ILD5@springfield-ongov. Springfield,Oregon 97477 You will need to complete application, save as, then attach to Engineering &Transportation Services Division email or print and bring to Public Works City Hall. Phone (541) 726-3753 You will need to come to Public Works, City Hall to process permit. -• 1 -Location of • Who is filling out the application? In this section, you will need to identify the Applicant, Owner of the abutting property, and the Contractor, if applicable. Example: John Doe is the owner of the 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. Site Address or Location: 4740 MAIN ST, SPRINGFIELD OR, 97477 Applicant: BARON BRAATZ Email Address: bbraatz@inncline.com Owner: 4740 MAIN, LLC Address: 1824 GARDEN AVE. City: EUGENE State: OR ZIP: 97403 Tax Map 17-02-32-42 Tax Lot 100,101,102 Phone: 541-953-8089 ------------------------ — - - - - - Phone: 541-953-8089 Contractor: CASCADIA CONSTRUCTION AND PLUMBING, LLC Phone: 541-554-4307 Contractors Registration (CCB) #: 205034 Expiration Date: Project Supervisor: WCD GROVER Phone: Insurance !X Proof of Insurance, minimum $500,000 coverage limit Utilities Does your utility company have a franchise agreement or license with the City? Please identify which type of agreement you currently have with the City. Franchise Agreement License Name of other utilities if this is a joint project: Intent of project for other utility who will own any facilities placed in right of way: Step 2: Description of Project What We of work do you need to do? In 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, start time of day and end time of day, of your project. It is important that you give time of day that you are requesting for your project work. There are codes and inspections that are time sensitive. -Identify 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. -Identify 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. .x Placing new facilities in the right of way Repairing/maintaining existing facilities Project TWO DRIVEWAYS ON SITE ARE BEING RECONSTRUCTED TO MEET ADA COMPLIANCE. ONE DRIVEWAY IS BEING REMOVED AND BEING REPLACED WITH SIDEWALK. A STORMWATER CONNECTION IS BEING MADE THAT WILL EXTEND INTO THE BIKE Description; LANE OF THE RIGHT-OF-WAY. Period of use or time of construction: 7am to 6 pm only, unless it's an emergent, From Date: JULY 15 Daily StartTime: 7AM To Date: JULY 31 Daily End Time: 6PM TOP: Answer these questions next r Are you working in the right of way or connecting to City facility? If yes, continue at Step 2a: Work Site Area Are you storing material/objects in the right of way other than during hours of work? If yes, continue at Step • Submit a Work Plan Step 2a: Work Site Area jK Cut I! Bore Other. Length 9 Depth 4,75 Width 2 Height 0 Existing Surface Material: NATIVE SOIL AND ASPHALT Surface replacement material to be utilized: SOIL AND ASPHALT Backfill material to be utilized: NATIVE SOIL, CRUSHED ROCK, AND ASPHALT System Connections to City Infrastructure 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. Wastewater Connection I— To Stub F Main Line (— Other: iX Stormwater Connection (— Catch Basin/Bubbler r Stub rx— Main Line Description: NEW CONNECTION TO STORMWATER LINE IN RIGHT-OF-WAY FROM A PRIVATE WATER QUALITY STORM FACILITY. Safety and Environment Air uali Type of Dust Control to be utilized: Stormwater Pollution Preventic You are required to call: The Lane Utilities Coordinating Council's "One Call Number" 811 or 1-800-332-2344 48 hours before digging. 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, 1.1 TMAARCI. 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. Dewatering Soil Erosion Hazardous material storage/spill prevention Ix Sawcut slurry runoff Site runoff/sedimentation Wastewater 5010--" Directions: City policy requires that all work performed in the City right of way/easement 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 shall take all reasonable precaution to avoid spills and shall immediately notify City of Springfield Maintenance /ZU-s�. or 541 726-37r' • a;* curs Emerge- -_ _ "------,� Team 541 953-3428 in the event of a spill. Plan submittal for Wastewater main line work ;_ Bypass pumping r Temporary plugging of sanitary main Traffic Control Plan Criteria for Citv of SDrinofield 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 Temporary Traffic Control Handbook Plan Submittal requirements: Submit your Traffic Control Plan (TCP) with the following information on 8.5"x11" or 11 "x17" 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/menuonlineform! 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: www. oregon.gov/ODOT/HWY/TRAFFIC-ROADWAY/docs/pdf/OTTCH 06.pdf?ga=t F_ Traffic Control Plan attached in email to Land Development; LDS@springfield-or.gov No Traffic Control Plan r There are no public traffic safety issues with this application. Step 3 -Submit a Work Pan What kind of work plan do you need? You will need to submit a copy of the work plan, which includes: X Site location and vicinity map Identify extent of excavations FT include North arrow. or bore locations. Outline limits of disturbance/ of work area. Show location of utilities within right of way. Identify pipe identify staging/material (X size and type, mainline connection location, and >x storage areas. connection type. Work Plans attached in an email to Land Development; send to LDS@springfield-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). Information Fee Encroachment/Placement Permit $335.00 Fees that may apply -A 5%Technology Fee will be applied to the total cost of the permit for processing the application. -A $1030.00 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 Cityof Springfield are subject to deposits or other approved forms of financial security that may include performance bonds, set-aside letters, or irrevocable letters of credit. The type of 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 11 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 R uiredwww. code.0 code rip fief defines when you need an encroachment permit. When do you need a Placement permit? Municipal code 3.224 Placement of Devices or Structures in the Public Way [ httpJ/www,cicode.usfcodes/saringfield/i defines when you need a placement permit. Step 5: Signature Signature Date: Check one: r Owner F_ Applicant r Contractor I— Utility Project Manager You are required to call: The Lane Utilities Coordinating Council's "One Call Number" 1-800-332-2344, 48 hours before before digging. i Page 3 of 3 .AC00 i CERTIFICATE OF LIABILITY INSURANCE DATE(MMroDlYYY1t) 106/12/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Commercial Contractors Bonding & Ins LLC 25920 Alfalfa Market Rd Bend OR 97701 CONTACT PNONE 541 389-4357 FAx 541 317-9062 EMAIL infoOccitlins.net INSURER(Sl AFFORDING COVERAGE NAIC # INSURER A: Associated Industries Insurance Company Inc INSURED CASCADIA CONSTRUCTION AND PLUMBING LLC 1824 GARDEN AVE SUITE 105 EUGENE OR 97403 INSURER B: Great American E&S Insurance Company INSURER C : SAIF INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTRI TYPE OF INSURANCE ADDL SUB POLICY NUMBER POLICY EFF (MM/DDfYYYY) POLICY EXP (MMIDDIYYM LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X� OCCUR X X _ AES105372600 06/30/2018 06/30/2019 EACH OCCURRENCE $1,000,000 DAMAGE S ( RENTED 100,000 MED EXP Any one person 5000 PERSONAL & ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY � JEC _ F LOC OTHER: GENERAL AGGREGATE $2,000,000 PRODUCTS - COMP/OP AGG$2,000,000 $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ (Par 1�.rjrlw2) B X UMBRELLA LIAB X EXCESS LIAR OCCUR CLAIMS -MADE X X 2571108 06/30/2018 06/30/2019 EACH OCCURRENCE $1.000,000 AGGREGATE 1 000,000 DED RETEN C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y N OFFICER/MEMBEREXCLUDED7 (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA X 797345 01/01/2019 01/01/2020 X I PER LfrF:OTH- qTAT FR E.L. EACH ACCIDENT $500,000 E.L. DISEASE - EA EMPLOYEE $500,000 E.L. DISEASE - POLICY LIMIT 500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) G1:11 1 RIGA I t MULDEK -INSURED ONLY FOR PROOF - SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD