HomeMy WebLinkAboutPermit Sidewalk 1999-05-24225 FFTH STREET
SPRINGFIELD, OREGON 97477
ENGINEERING DIVISION
oFFlcE TELEPHONE (503) 726-3753
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5-Z,J4/5 PERMIT NUMBER:
DATE ISSUED:APPLICATION DATE:
SITE INFORMATION
SUBDIVISION:
HONE
TAX MAP:
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PHONE
ZIPSTATE
4
OWNER:
CITYADDRESS
STATE
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CITY
LOCATION OFWORK
APPLICANT
ADDRESS:
REOUESTED PERMITS:
I PROOF OF INSURANCE: $5OO,OOO MINIMUM lF WORK lS DONE BY PROPERTYOWNER )
$ 60.00
@$0.06 sF.-)
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TOTAL DUE WITH PERMIT $
q(fewatx I ..$ 10.00.REPAIR
AMMOUNT OF SIDEWALK IN EXCESS OF gOFT
E DRIVEWAY/CURB'CUT/SIDEWALK: ..
fl ADDITIoNAL DRIVEWAY .......,$ 30.00-
CONTRACTOR INFORMATION :
ADDRESS: PHONE
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Y;OCONTRACTOR REGISTRATION NO
PROJECT SUPERVISOR:,{eu nt
CONTRACTOR:
RATION DATE
PHONE:
INSPECTIONS
AN INSPECTION REOUEST SHOULD BE MADE PBIOR TO POURING CONCRETE, AFTER THE PROPOSED WORK HAS BEEN FORMED
AND MADE READY TO POUR.
cuRB cuT AND SIDEWALK tNSPECTIONS 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: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.
YOU ARE REOUIRED TO CALL
THE LANE UTILITIES COORDINATING COUNCIL'S"oNE CALL NUMBER" 1-800-332-2344
48 HOURS BEFORE DIGGING
SIGNATURE:
Bv sionature. I state and aqree. that I have carefullv examined the completed application and do herebv certifv that all information herein
is'tru-e anO Correct.-anO I f[rtheir certifu that anv an'd all work performed shall b6'done in accordance wlth the Ordinances of
the eitv of Sorinofield. aoolicable Citv'Standard soecificationb and Drawinqs, and the laws of the State of Oreqon pertaininq to the work
desqr.ibed hdreinl I furthbi certify that only contrabtors and employees whd are in compliance with ORS 701,055 vtill be usdd
on this project.
llu4llof qqtg.e tg el!ure lltq! alJ required,inspections.are r.gqugslgq at the proper time, th.at project address is readable from theslreel, ano Ine approveo set or plans wlll remaln on tne Srte at all trmes dunng construction.
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DatcSignaturec
AMOUNT RECEIVED
RECEIPT NO:RECEIVED BY
DATE PAID
O City of Springfield O
DRIVEWAY/SIDEWALK PERMIT APPLICATION
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