HomeMy WebLinkAboutPermit Sidewalk 1999-05-27I -N I L\ED -I
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225 FIFTH STREET
SPRINGFIELD, OREGON 97477
ENGINEERING DIVISION
oFFrcE TELEPHONE (503) 726-3753 Z
APPLICATION DATE:
PERMIT NUMBER:
DATE ISSUED:
SITE INFORMATION:
ADDRESS: )\5O $it\ s{, crry,Sof\nq$ie\d SrArE: DR ,,r,Q1tll
NE
STATE:.,*,5o$ \d,
PHoNE: ..l{ tl- 5q 3 D(
OWNER
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LOCATION OFWORK
APPLICANT
-l-
SUBDIVISION
REOUESTED PERMITS:
I onvewaY/cuRB-cur/STDEWALK: ......
AMMOUNT OF SIDEWALK IN EXCESS OF gOFT
E SIDEWALK REPAIR:
TOTAL DUE WITH PERMIT $
E ADDITIONAL DRIVEWAY
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$ 60.00
$@$0.06 sF.
,...........$ 10.00
...........$ 30.00
CONTRACTOR INFORMATION :
pHoNE: Ir.{ 17 _o rl 5 O
0 o 0-c
1
efu
EXPIRATION DATE
PHONE
CONTRACTOR REGISTRATION NO
PROJECT SUPERVISOR:
CONTRACTOR
ADDRESS:
INSPECTIONS:
AN INSPECTION REOUEST 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 726.3769 (RECORDER) STATE YOUR DESIGINATED CITY JOB NUMBER/PERMIT
NUMBER, JOB ADDRESS, TYPE OF INSPECTION REOUESTED, AND WHEN YOU WILL BE READY FOR INSPECTION, CONTRACTOR'S
OR OWNER,S NAME AND PHONE NUMBER. REOUESTS RECEIVED BEFORE 7:OO A.M. WILL BE MADE THE
SAME DAY, REOUESTS AFTER 7:00 A.M. WILL BE MADE THE NEXT WORKING DAY. INSPECTIONS ARE TO BE CALLED lN
AFTER EXCAVATIONS ARE MADE AND FORM WORK IS IN PLACE BUT PRIOR TO POURING CONCRETE,
YOU ARE REOUIRED TO CALL
THE LANE UTILITIES COORDINATING
"ONE CALL NUMBER" 1.800.33
48 HOURS BEFORE DIGGING
COUNCIL'S
2-2344
SIGNATURE:
Bv sionature. I state and aoree. that I have carefullv examined the completed application and do hereby certifu that all inforJnation herein
is1ruEi irid coireEt. anO tlirthijiCertifu inaranV an'd all work performed shall b6'done in accordance with tf e Ordinances.of
rhe ei-tv or soiinofieio -aoor1sftb,f,f;LYoTnlsslt
lga?g:?'l"J,i.3Li,3J3yfi3?,x"ifl
,J1""iiffi"?r",i,,:,i,6'fis"1gi:oto51fifi11't,ssj" the work
de-scri6ed herein: I furth
on this project.
The Citv mav insoect the work site described in this permit at anv time during a one Vear period following the receipt by the City of. notict
of comoletion of 'the described work and soecifu. at the Citv's sole descressidn, anv 6dditional restoratioa work required to retutn the.slte
td ;;i;hd;rd ac'ciiotablelo the Ciiv. Tne pErmitt6e wltt Ob fiotiiieO ih writing of'anywork required anQ will have thiity days (30) from the
date of the notice io complete the work. Work not completed at the end of Ihe thirty days will be performed by
the city and the costs will be billed to the permittee.
lfurthor aqree to ensure that all required inspections are requested at the proper time, th.at project address is readable from the
street, and the approved set of plahs will remain on the site'at all times ddring construction.
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Date 5- A r?q q
34 z-\ =
I
AMOUNT RECEIVED
RECEIPT NO:
DATE PAID
RECEIVED BY:
Signature
I City of Springfield t
IVEWAY/IDEWALK P RMIT AP LICATION
I PRooF oF INSURANCE: $500,000 MINIMUM lF WORK lS DONE BY PROPERWOWNER
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ADDRESS: 1[Sc m\\t 5{'TAX MAP: