HomeMy WebLinkAboutPermit Sidewalk 1999-08-13225 FIFTH STREET
SPRINGFIELD, OREGON 97477
ENGINEERING DIVISION
oFFtcE TELEPHONE (503) 726_3753
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PERMITNUMBERI q? III+
APPLICATION DATE Y-4 fr DATE ISSUED: 14U6, 13, r l gg
SITE INFORMATION:
SrArE: Dn. Zn: taxrcr:$fifj/ z{_
LOCATION OF WORK:
TAX MAP:
ADDRESS:STATE
tA
CITY
PHONE2il _/94. t
PHONE:I LG-I n5r ,
lrv\? a^J.,,- r(SUBDIVISION' L,rt o
OWNER
CrY' S?T I J
ADDRESS:
REOUESTED PERMITS:
I PROOF OF INSURANCE: $50O,OOO M|N|MUM tF WORK tS DONE By PROPERTYOWNER
60, oo
....$ 30.00
TOTAL DUE WITH PEBMTT $
,r@
(ontvewa
E ADDTTTONAL DRTVEWAY
E SIDEWALK REPATR:........
AMMOUNT OF SIDEWALK IN EXCESS OF 9OFT @$0.06 sF.
...........$ 10.00
$ 60.00
$
CONTRACTOR INFORMATI ON:
e 7
Z2o0qD?3
PROJECT SUPERVISOR, G.*-
CONTRACTOR REGISTRATION NO 4L PHONE:
EXPIRATION DATE:
PHONE:
CONTRACTOR
INSPECTIONS:
AN INSPECTION REOUEST SHOULD BE MADE PRIOR TO POURING CONCRETE, AFTER THE PROPOSED WORK HAS BEEN FORMEDAND MADE READY TO POUR.
cuRB cur AND SIDEWALK INSPECTTONS CAILTSq-.326^9_{IECORDqRIITATE youR DES|G|NATED Ctry JOB NUMBER/PERM|rNUMBER, JoB ADDRESS, rYPE oF lNSPEcrlqryjF_o^qEa-TED, AND wHEN you w[[ af nEAov ron},tspeclor{ coNTRAcroR,sOR OWNER'S NAME AND PHONE NUMBER. REOUESTS RECEIV'ED eErOnE 7:00 A.M. W|LL BE MADE THESAME DAY, REQUESTS AFTER 7:00 A.M. wlLL BE wtAoE irE-tlrxr wonrtlvc-oaV. ir'rspEtloNs ARE To BE cALLED tNAFTER EXCAVATIONS ARE MADE AND FoRM woRk lslnr prabi'aur rnron ro pouRtNG coNCRETE.
THELANE-uILL.rfi"fS:caUHBifiATrruccouNcrL,s
"ONE CALL NUMBER" 1.806:{SI-1g44
48 HOURS BEFORE DIGGING
SIGNATURE:
By signature, I state and. agree, that l_have carefullV examined the comoletedrs true ano correct, and I turlher certily that anv and all work performed shallthe Ci.ty of Sprinsfie-td, appticabte Citv'siarioaitl ipec'ltiiiiiijirS;n;' D;;;i;;;.
3i.ti1,S3p"L%€rn, I further certity that onty contrabtors and emptoyes: wh6 .i
Ift"'tU +a'r'a??fs!T,:%lYBi5'il8,fl?:"'irg8gJ,?,:Ti ph:dB,',',{Bilriixs"?JJl?Br1 sffJa'E[g?'J?p.!?XpJLBH,]x"",ii:?stBu Il
h",,1:d?lfsh%fi38",8'?B',iri:'"',[,incJ'["',[:'R,"JflllliiHl.1tg;ts'Xl",flJ,."HJ[?i."Ji?,?xr%#ffiidi{*1#3;# iEik"i'ui;
the City rnd thc oortr willbe billgd to thapbimiriid,- ' -'"-
I furthor aoree to ensure that all required insoeqtions are requested at the proper time, that project address is readable from thestreet, and the approved set of plahs wiit iefrain cin t6e iiidit aiit'iribs dtjring bonstiuitiohi"
Signatu
I
Ba<r
Date
he
e
re CO
tt
alln and ation herein
the work
PAID
RECEIVED BY:o)izzt
ooAMOUNT RECEIVED
RECEIPT NO:
Clty of Sprlngfield a
DRIVEWAY/SIDEWALK PERMIT APPLIGATION
*-'
S. qq& +-
^*
ADDRESS: