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APPL ICATIOI.I / PEEIIT
SPRINGFIELO
225 NORTH FIFTI{ gTREET
9FR|hI3FIELD, OREGON 91411
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9ECOND DRI\EII,IAY ( gEE TRAT+IC )
R=AUIRE9 AFPLICATION FOR A SECot'lD DRt\€tUAy(T-4.ta)
OR A COUNTY APPLICATIO?'I rcR FACILITY P=Ri-1IT (C AO.2@))
IF IN THE U.6.E.
'5'Lt , -77-'DATE.OF APFLICATIO'hI
ADDRE9g PHONE:
12b-3169
RE@IIE9T:
) STATE YOUR CITY DESIGNATED JOB NtJ'i.19=R, JO3 ADDRESg,TYPE trD AJ.ID [T.H=N YOIJ IUILL B= READY FOR IN9PE CTlOfl, CCtITRACTOR9 oR OtJ.t.lERg N+1E Ar.lDP}.IO,{E NLMBER R=AUEgTg RECEI\€D BEFOFE 1,OO Nl UILL BE HADE TI{= 9A1E DAY, FEOJEST9 AFTER liOOAH U,,ILL BE T,IADE TI]E NEXT IUORKING DAY
EXIgTII.{G ELIILDIN6 PER'IIT NO. ( IF APPLICABLE )
*YOUR CITY TED JOE NO.,ef a'zo +1qsEE BOOK
9IDEIUALK / DRI\EII.JAY
FOR ALL CONCRETE PAVING IUITTIN
THE STREET RIGHT OF IUAY, TO 3E
MADE AFTER ALL EXCAVATIN6
15 COI'IPLETE AID FORI1 IIJORK
AID sUB.BA,gE HATERIAL 19
IN PLACE
CU@ / APPROACH APROI.I:
AFTER FORF1s AE EECTED
BUT PRIOR TO POIJRING
CONCRETE.
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COiII-IERICAL DRI!€UAYs SHALL
HA\G 5'TO A'FLAIRS3'. O'STADARD
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$*oTOTA PERI'IIT FEE:
I iA\€ CAREFULLY EXAYINED TH= COI1PLETED APPLICATION FOR PEBIIT, A{D DO HER=BY C=RTIFY THAT ALLiNTSIATIOI.I I]EREON 15 TRUE A\D CORECT , A\D I FURTI-.IER CERTIFY ]'I]AT A\Y A\D ALL Ui2R< PE=O31=Dg;ALL 3E DOh,IE IN ACCORDANCE I.iJIiII Tit=ORDINA\CEg OF TI{E CITY G SPRINr.#IELD, A\D Tr.lE LAII,9 C THESTATE OF OREGON PERTAINING TO TI.1E IIJOR< DESCRIB=D IiER=IN, AND TiIAT NO OCCUPA\CY UILL 9E IIAD=G A.IY STR.JCTURE IUIT|]OJT PEB1 r99lo,i! 6 THE BUtLDtN6 Dtvtgtof{ I FURTI{ER CERTIFY THAT ONLY CONTR,ACTORS
TI{I3 PROJECTA\D [J+{O COI'1PL|A\ICE IUITH ORg lolg>> tUtLL BE U5ED Ot{
DATE
3 ,Zl- 7a_-
FEAUIRED tNgPECTICt.Ig