HomeMy WebLinkAboutPermit Sidewalk 1999-11-18225 FIFTH STREET
SPRINGFIELD, OREGON 97477
ENGINEERING DIVISION
oFFtcE TELEPHONE (503) 726-3753
- 77 5APPLICATION DATE:
PERMIT NUMBER:
DATE ISSUED:
SITE
PHONE
STATE AX LoT: .J4 7Ad
{ag-
ADDRESS:
CITY:
ADDRESS:2 ?Ava Tt4A.
TAX MAP:
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LOCATTON OFWORK
APPLICANT
SUBDIVISION;
OWNER:HONE
STATE: A-<-
REOUESTED PERMITS:
I PROOF OF INSURANCE: $5OO.OOO MINIMUM IF WORK IS DoNE BY PRoPERTYoWNER
TOTAL DUE WITH PERMTT $
.$ 30.00
@$
$ 60.00
E ADDTTTONAL DRTVEWAY:
E DRIVEWAY/CURB-CUT/SIDEWALK: ...........
AMMOUNT OF SIDEWALK IN EXCESS OF gOFT.
CONTRACTOR INFORMATION
3zo7
a
ft
a
,lPROJECT SUPERVISOR
PHONE
CONTRACTOR
ADDRESS
EXPIRATION DATE
PHONE:
CONTRACTOR REGISTRATTON No: { ;
E PRIOR TO POURING CONCRETE, AFTER THE PROPOSED WORK HAS BEEN FORMED
cuRB cur AND STDEWALK INSPECTIONS CALL 73q-.3.Zqe_BECORDEII STATE YOUR DESTGTNATED Ctry JOB NUMBER/PERM|rNUMBER, JoB ADDRESS, rYPE oF lNSPECTtgry3S-qt1qs_r-EInl.io wHrN You W[f ain|aoy FoR tNSpEcloN, coNTRAcroR,soR owNER's NAME AND PHoNE NUMBER. REoUESTS-Rc crive o arroAr 7'0d ti.M,-fi/ili'er Nrnor rHeSAME DAY, REOUESTS AFTER 7:00 A.M. wtLL ar vraoe inE-rvrxr wonkrllc oai. ir,r5pEcloNs ARE To BE CALLED tNAFTER EXCAVATIONS ARE MADE AND FORM WORK rSIr.I Pr-Abt'ELJT PNrON TO POURING CONCRETE.
rH E LANE
-u Tr L diH$'eb'dHtsiRrth nr c"ONE CALL NUMBER" T.A(i0--35
AN INSPECTION REOUEST SHOULD BE MADAND MADE READY TO POUR.
48 HOURS BEFORE DIGGING
COUNCIL'S
2-2344
SIGNATURE:
py signature, I state ancis'ti'{E arid soirar, ,;d1_?$lt"h"#ls.li+il?f5r?llllvd"ujr',ffi?f$J}:ffimir8fl6gts'i.".J,i,i,".?g,.oo?,isJ",filfF{g%}[ijf,ir in{ormation herein
$i"rfi,i,Hf,"1"4pilql?L%f;Brx!l.Pi,,f;1'rHtsir?;is?I:*%'*gr*#vjr$tHilr*ri;"*[:,f,Bt3iBii:"#?#rrT,u*",he work
IiE":dH'Hi"I.3j"Hq!:ff"fiqi['u1ft??]'slEFd'k#?ffd$"x1;[h'ffiff#-hi*.,ig,i':ffin,pjl*id$sJ]'ffi
date-of the notice to complefe trre iyoiriWdik't;t ciimfl;t"i;t tEe'e;ith€ City tnd tho cotb will bo biltod io tfra peimrttoa,
r[iJ:t:!flBli%,Bo"J]'"iLT!B[sl;?"r"1'fi,i,,ij&?il""H,f..fJfs:?:]rt1.f,1|hs#isg?H[lp,illi3,.rroject address is readabre rrom the
Signature Date
m
AMOUNT RECEIVED:DATE PAID
RECEIPT NO:RECEIVED BY
LICATIONPERMITAPP
ofCity
DRIVEWAY/SI
?)/- 7j*/
ts-STDEWALK REPATR:...$ 10.00.
INSPECTIONS: