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S=COND DRIV=UAY ( 5== TRAFIC )EAUlRis APPLtCATtctt FOR A *CoND DRtvZaAy(n-t.ta)OR A C{2JNTY Affi-ICAiION FOR FACILITY P=SIIT (C ZA.2O3)IF IN TH= UG3.
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PROCEDUE rcR N9PECTIChI REA'JEST:
C/JJ. 12b-3'169 (ECOrcER ) STATE YOUR CITY D=9IGNAT=D JO3 NLJI-1==R, JOg ADDR= 95,7T?= GINgF=crlohl reauEgrED A}JD uF{EN you u,rLL B= =ADy rcR Ngp=crrcrr, coNinaiio=s oR ouN=Rg NAr= .4\DPHOr{= Nt-[-13=R. R=AU=ST5 R=CEIV=D B=. re \oo ts1 l,ulLL 3= HAD= Ti-4= 5A]1E DA.r, R=AJ=gTS A=iER.i.O.eAY IIJILL ts= I-IAD= TH= N=XT I,I.JOR<IN3 DAY
EXlSTll'{'- SUILDING P=RilT NO- f F A??LICAVL=- )
JK YOUR CITY D=5IGNA *NO. t3;9;= w.
REAUIRED IN9FECTICN9 SID=IUALK / DRI\EIIJAY
FOR ALL CONCETE PA\/ING tUiTi-.IIN
THE STREET RIGI]T CF IUAY, TO 3=
IIAD= .€TER AL EXCAV.ATNG
15 c.oi-'iPLETE Al.iD FOBI UJOR<
AND 5U3.3A5= HATERIAL 15
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C.Oi-IHERICAL DRIVEuJAYS SI]AL
HAVE 5' TO A'FLAIRS
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x',TOTAL PERI-IIT FEE:
r llve ca*=rullr EXAY|N=D CO|-'IPLETED APPLICATiOI{ FOR PEE.1IT, A\D DO l.lER=BY CERTIFY :tlZT ALL
STALL BE DONE fh{ ACCORDANCE tulTl-{ Tr'l= OPDIN:NCE, G THE CITY oF SPRINC,FIELD, AID Tl-.1= LAtllS G THE
STATE OF OREGON PERTAINING TO TI]E U)OR< DESCRIS=D H=REIN, A\{D T|..IAT NO OCCUPANCY tUiLL 3= IIAD=G ANY sTEL'CTUR= UIITI]CJT PEBII9SIOI{ G THE BUILDING DI\49I?T{. I FURTIiER CERTIFY TI.{AT ONLY C,ONTRACTORS
AND EI-1PLOYEES UJi-{O AE IN COI'1PLIA{CE IIJITI{ ORg 1O1O'5 TUILL BE US=D ON TI]I5 PROJECT.
SIGNED DATE
AtrLICA,TION / PE&1T
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