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HomeMy WebLinkAboutPermit Encroachment 2019-07-25 (2)I Reset Form I 225 Fifth Street Springfield, Oregon 97477 Engineering &Transportation Services Division Phone (541) 726-3753 Step 1 -Location of Work I Print Form I 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: -N ho f•* Nal ia.,l 21" Applicant: Email Address: e pjJ� �r ax iap Tax Lot -?,qA� U.WGIO+�$CD[Si� � ��W�- _ Phone:J��%�-ad-5-aa-66 Owner: Ato I Fro }� {'.� Phone: Address: 7Cu_Ofcoutea( City: Sp C;svfjc4a state: O0. zip: 974"77 Contractor: Pr GL Phone: Contractors Registration (CCB) #:, ;].1� 5 Expiration Date: i Project Supervisor: W� !A + Phone: 07f - 8ig- S 766 Insurance F- 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. F_ Franchise Agreement I— 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 Whattip+ a 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. F7 Placing new facilities in the right of way (— Repairing/maintaining existing facilities lrll= W G'..1C'AV-"!"lJ��J� �..t VI Project Description: 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.sprin. fie.ld-or.Aov/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. ODOTs Traffic Control Handbook website: www. oregon,gov/ODOT/HWYITRAFFIC-ROADWAY/docs/pdf,OTTCH 06.: df?.,a=t F_ Traffic Control Plan attached in email to Land Development, LDS@springfield-or.gov No Traffic Control Plan F There are no public traffic safety issues with this application. Step 3 -Submit a Work Plan What kind of work plan do you need? You will need to submit a copy of the work plan, which includes: Site location and vicinity map Identify extent of excavations include North arrow. or bore locations. Outline limits of disturbance/ F_ of work area. Show location of utilities within right of way. Identify pipe F– size and type, mainline connection location, and identify staging/material connection type. storage areas. 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 $345.00 Fees that may apply -A 5% Technology Fee will be applied to the total cost of the permit for processing the application. -A $1061.00 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 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 WorkOpr Under.Surface—Encroashma..nt.P..er..m...i..t.Rmtjired [htt;)://www.gcode.us/codesLs rin fiel defines when you need an encroachment permit. When do you need a Placement permit? M_unicigal code 3.224 Placement of Devices or Structures in the Public Way-S.http://www,gcode.us/co des.+springfield/j defines when you need a placement permit. Step 5: Signature Signature Date: Checkone: F–, Owner F_ Applicant r Contractor r 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. Page 3 of 3 Page 84 2011 Edition Stationary Lane Closure with Flagging Diagram 320 Diagram 320 covers total closure of one lane of a two-lane, two-way roadway. See the detail inset for the layout if using a single flagger to control both directions of traffic on low volume roads (less than 400 ADT) with good sight distance as discussed below. 1. Use truck -mounted flashing warning lights on work and protection vehicles. See Section 4.3 — Lights and Lighted Signs for exceptions. 2. For added visibility, a truck -mounted arrow board or PCMS in caution mode may be used. 3. Flaggers at each approach are required if any of the following conditions exist: a. Night Operations. b. Work space is over 200 feet in length. c. Sight distance is less than 750 feet from each approach through the lane closure. d. Traffic volumes are greater than 400 ADT. 4. The length between the Flagger Ahead signs shall not exceed one mile. Use Diagram 340 — Lane Closure with Pilot Car if exceeding one mile. 5. Cones should be used to outline the work space when curves or other roadway alignments prevent clear direction for the motorists to pass the work space safely. 6. Cones along the work space are recommended when posted speeds are 45 mph or greater, when working under heavy traffic or when travel lanes are narrower than 11 feet. 7. Extended queue signing (see Diagram 5-4) should be used when traffic queues extend beyond the initial advance warning sign. 8. When flagging near an intersection, the "Flagger Ahead" (CW23-2) sign should be visible to traffic entering from any side road. Additional advance warning and Flagger Ahead symbol signs may be placed on the side road(s). 9. Sign set-up and flagger placement shown may be used for intermittent full road closures of 20 minutes or less. 10. The "ONE LANE ROAD AHEAD" (W20-4) sign is optional and should be considered on high volume or high speed roads, or when extended queues are expected. Chapter 5 September 2016 2011 Edition Stationary Mane Closure with Flagging Y v Q QQ Q 06 _ o<r XZ� _ O zc¢ 0 W m NV �. 14! ----------------- 111111 I � I I -A$ t I j � I o J16 1 a.E Z OMS �•• v m F :� Q I sr I N I r I Sim Snacine and Buffer Leneths (feetl Pasted SPWO SP?Ci48 Between Sites "Buffer" 4 C sisaae 20 25 30 _— 50 100 100 100 75 100 35 40 350 350 350 125 150 45 500 500 180 500 210 250 50 55 700 700 285 700 325 365 *1610_ 1t ■o Page 85 Diagram 320 t V LU V�LU Z September 2016 Chapter 5 CERTIFICATE OF LIABILITY INSURANCE DATE(MM1DDNYYY) 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 have ADDITIONAL INSURED provisions or 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 I.UN,A`., Nick Coats United Insurance Agencies, LLC VE 541 242,.6464 I FAX 54242-64 PO Box 2589 E-MaL NIc iia—non.com Eugene OR 97402 R S AFFORDINGCOVERAGE N _ IN$, RERA: American Hallmark insurance Co of Texas INSURED IN UREA B! Saif CO oration Alpha Plumbing & Rooter Service, LLC IN URE C: 3015 Kincaid St INSURER D: Eugene OR 97405 N5URFR E: 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 LTRX TYPE OF INSURANCE ADDL UB pOL,CY N MBER POLICY EFF POLICY EXP LIMITS A COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X� OCCUR Y 44CL607363 Ofi/01/2018 06/0112019 EACH OCCURRENCE S11,000,000 DAMAGE TO RENTED $ 100.000 MED EXP (Any one ersom $6.000 PERSONAL & ADV INJURY $1,000,000 GEM& AGGREGATE LIMIT APPLIES PER: POLICY XdECT LOC GENERAL AGGREGATE S 2 000 000 PR- COMP/OP AGG 5 2 OOO 1)00 —ODUCTS S T R• AUTOMOBILE LIABILITY j COMBINED SINGLE LIMIT $ 1,000,000 A ANY AUTO BODILY INJURY (Per person) $ OWNED X SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED X AUTOS ONLY X AUTOS ONLY Y 44CL607363 06/01/2018 06101/2019 . BODILY INJURY (Per acciderit)i S PROPERTY DAMAGE $ $ A X UMBRELLA LIAB X OCCUR EXCESS LIAR . CLAIMS -MADE Y 44CL607363 0610112018 06/01/2019 EACH OCCURRENCE S1,000,000 AGGREGATE S 1 000 000 ! WORKERS COMPENSATION AND EMPLOYERS' LIABILITY_ B ANY OFFICERIMEMBERPEXC UDER� CUTIVE Y!❑YN (Mandatory in NH) NIA 883975 06/02/2018 106102/2019 X PER 07H- E.L EACH ACCIDENT S500,000 E.L. DISEASE - EA EMPLOYE $500,000 E.L. DISEASE -POLICY LIMIT $ 50A000 If es, describeands P DESCRIPTION OF OPERATIONS I LOCATIONS f VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) AVENUES RESIDENTIAL LLC AND THE OWNERSHIP ENTITY(S) OF THEIR OWNED OR MANAGED PROPERTIES have been included as an ac required by written contract on the general liability policy as their interests may appear, subject to policy term, conditions and exclusions with respects to work/service performed by the named insured. Per form MP9767 CERTIFICATE HOLDER CANCELLATION Avenue5 Residential, LLC c/o Registry Monitoring Insurance Services, Inc. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 5388 Sterling Center Drive AUTHO DR E I Westlake Village, CA 91361 ©1988.2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD