HomeMy WebLinkAboutPermit Sidewalk 2001-03-22SPRINGFIELED
Job# 01-00281-01
COMMERCIAL PERMIT
City Of Springfietd
Community Services Division
Building Safety
Page 1 ot 2
Job Number: 01-00281 -01
Office:726-3759
!nspection Line: 726-3769
Tax Lot#: 06700
Subdivision:
225 North Fifth Street
Springfield, OR97477
Location Of Proposed Site: 205 00023rd St Spr
AssessorsMap#: 17033614
Lot: Block: Addition:
ctTY oF sPRt tGFtELq OREaON
Owner: general assembly church
Address: 205 23rd street
Scope Of Work: Sidewalk
sdiewalk repair - 2 sections
Phone Number:
City/State/Zip:
Repair
541-485-6742
springfield, OR97477
Value: $O
Quad Area:
# Of Units:
Constr. Type:
Water Heater:
Office Use
-
Land Use:
Zoning Code:
Bedrooms:
Range:
# Of Buildings:
Occupancy Group:
Heat Source:
Sq. Footage:
To request an inspection call the 24 hour recording a1726-3769. All inspections requested before 7:00
a.m. will be made the same working day, inspections requested after 7:00 a.m. will be made the following
working day.
Required lnspections
Public Works
SW-Setback -After forms are erected but prior to placement of concrete
Construction Types:
Occupancy Groups:
# Of Buildings:
# Of Bedrooms:
Handicap Access?
Area (Sq. Feet)
Main:Accessory:
# Of Stories: Height (feet):
Current Units: Proposed Units
Census Code: Does not apply
Total:
Fee Paid On Receipt# Value/Quantity Fee Amount
Pubtic Works
Sidewalk Repair
Total Public Works
$10.00
$10.00
Grand Total
03122t2001 4746 1
$10.00
Job# 01-00281-01 Page 2 of 2
By signature, I state and agree that I have carefully examined the completed application and do
hereby certify that all information is true and correct, and I further certify that any and all work
performed shall be done in accordance with the Ordinances of the City of Springfield, applicable City
Standard Specifications and Drawings, and the laws of the State of Oregon pertaining to the work
described herein. I further certify that only contractors and employees who are in compliance with
ORS 701.055 will be used on this project. I also understand the City may inspect the work described
on this permit any time during a one year period following notice of completion, at the City's
C\3 -zz-Ol
Signatu Date
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225 FIFTH STREET
SPRINGFIELD, OREGON 97477
ENGINEERING DIVISION
OFFICE TELEPHONE (503) 726-3753
APPLICATION DATET "b -
iffi PERMIT NUMBER:
DATE ISSUED:
SITE INFORMATION:
ONE
ctrY: sp z.rAX Lor: {+&
1/8S-L7y7OWNER:
OFLOCATION
WORK:
ZAPPLICANT
PHONE:
TAX MAP: t+O 37L (+
7?q ?7STATE:O (t- ztp,
5
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ADDRESS: aOS aBd :+
SUBDIVISION: -t<_.44
It-Lb
REOUESTED PERMITS:
fl CURB CUT/DRIVEWAY: NUMBER OF DRIVEWAYS X.............$ 6s.O0.....'..'. : $
E MULTIPLE PERMIT DISGOUNT EA: ....(MAX 2)........... ..$ 30.00.....
(MULTI PERMIT DISCOUNT GOOD FOR ONE SITE AND ONE SITE INSPECTION ONLY
APPLIES TO 2nd AND 3rd PERMITS ONLY. NOT SIDEWALK REPAIRI
TOTAL DUE WITH PERMIT $
fl PROOF OF TNSURANCE: $500,000 MINIMUM lF WORK lS DONE BY PROPERTYOWNER
/O.crb
$ 10.00
-s
........$ 65.O0
@$0.06 sF.
-A
-A
_ $ tb.6D
AMOUNT OF STDEWALK lN EXCESS OF 90FT._
El SIDEWALK REPAIR:...............
fl SIDEWALK:.......
CONTRACTOR INFORMATION :
EXPIRATION DATE:ro3a lg
PHoNE,'-ltlq-833th*do ?olsc\"-.)n-
L
L
o3
PROJECT SUPERVISOR:
CONTRACTOR REGISTRATION NO:
CONTR,ACTOR:
ADDBESS:il_eE:Sg33
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 7:00 A.M. WILL BE MADE THE
SAME DAY, REOUESTS AFTER 7:OO A.M. WILL BE MADE THE NEXT WORKING DAY. INSPECTIONS ARE TO BE CALLED IN
AFTER EXCAVATIONS ARE MADE AND FORM WORK IS IN PLACE BUT PRIOR TO POURING CONCRETE.
rHE LANE urrur'iE'dE66HBilttriiNc couNcrL' s" oNE CALL NUMBER" 1-800-332-2344
48 HOURS BEFORE DIGGING
SIGNATURE:
RECEIPT NO: RECEIVED BY
Bv sionature. I state and aoree. that I have carefullv examined the comoleted aoolication and do herebv certifv that all information herein is true and
c6neEt, and'l further certif'y thbt any and all work performed shall be dbne in abbordance with the Ordinances of
the Citv of Sorinotield. aoolicable Ciw Standard so'ecifications and Drawinos, and the laws of the State of Oreqon oertaininq to the work described
herein.'l further dertifi thit only contractors and employees who are in co'mirliance with ORS 701 .055 will belsed
on this project
The Citv mav insoect the work site described in this oermit at anv time durinq a one vear oeriod followinq the receiot bv the City of notice ofcompleiionoftkidescribedworkandspecify,atthe'Citv's sole'discretion,Snyadditionalrestorationwdrkrequiredto'returnttiesitetoastandard
acceptable to the.City. The permittee will be'notified i,n writing of any work reqirired and will have thirty days (301 from the date of the notice to
complete the work. Work nrit completed at the end of the thifty days will be performed by
the City and the costs will be billed to the permittee.
I further agree to ensure that all required inspections are requested at the proper time, that proiect address is readable from thestreet, and the approved set of plans will remain on the site at all times di.rririg constructiori.
LSignature o"t" 3- ZL-5)
AMOUNT RECEIVED DATE PAID:
O Cils of dprinsfield O
DRIVEWAY/SIDEWALK PERMIT APPLICATION
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