HomeMy WebLinkAboutPermit Encroachment 1987-10-22DEPARTMENT OF PUBLIC WORKS
?25 NORTH sTH STREET
SPRtNGFtELD, OREGON 97477
(503) 726-37s3
PUBLIC RIGHT OF WAY
ENCROACHMENT
APPLICATION
SPRINGFTELD
The applicant shall submit the following:
1. Two copies of the work p'lan.
2. If applicable' a copy of or certificate of insurance in a sum not less than $SOO,0O0.
per occurrence for property damage, persona'l injury or wrongful death, endorsed to
the City of Springfield (storage of articles during construction only).
APPL I CANT:
ADDRESS:
PHONE:
IP:
Project Supervisor:Phone:
I,lame of r (i work will be do y someone other than the appl icant):
Phone:. O
Contractor License Expiration Date:
Name of other utiljty if th.is is a joint project:
Work Site Location:
Purpose of the Work (Water, Gas, power, TV Line, Street Oiling, Etc.)01 .i7l
Type of Work: (a) Cut _ (b) Bore _ (c) Jack _ (d) Other
Amount of time Articles are to be stored:Di mens i on of Area : 7t, x
Description of Warhing Devices to be Ut.ilized:
Iype of Securi ty Depos.i t: Bl anke t Surety Bond Surety Bond Cas h/Check
Existing Surface Material :
Backffll Material to be Utilized:
Surface Replacement Material to be Utilized:
Type of 0i I Utit ized (Street 0i f .ing 0n1y) :
Project Beginning Date:Project Completion Date:
to comply with the requirements of City Code ?-5_6
icable city standard specifications and drawings and
Coordinating Council ,,one call number,,24 hours
Authorized Signature:Date:
)
before di gging/beginning work.
The undersigned hereby agrees
through 2-5-16 inclusive, appl
to contact the Lane Utilities
6 MONTHS FROM THE DATE OF ISSUANCE
THIS PERMIT EXPIRES
PUBLIC RIGHT OF W'
ENCROACHMENT
PERMIT
FOR OFFICE USE ONLY
Amount of Security Deposit
Fee: Storage of Articles During Construction
Fee: Maintenance Surcharge
Fee: Permi t
Total Amount to be Paid at Time of Permit Issuance
PLAN REVIEW COMMENTS / SPECIAL INSTRUCTIONS
ALL RESTORATION WORK SHALL BE IN CONFORMANCE WITH EXISTING CITY CODES AND tN
GOMPLIANCE WITH CURRENT STANDARD SPECIFICATIONS. EXCEPT AS NOTED BELOW.
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TYPICAL STREET CROSS-SECTION
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YOU ARE REOUIRED TO CALL
LANE UTILITIES COORDINATING COUNCIL'S
"oNE cALL NUMBER;' 342 - 6676
24 HOURS BEFORE DIGGING
THE
Plan Reviewed By:
Permit Issued By:
I ns pecti ons
Work in Progress:
At The Time of ComPletion:
El even Month:
Deposit Returned:
Date:
Date:
Date:
Date:
Date:
Date:
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