HomeMy WebLinkAboutPermit Sidewalk 1999-10-25I -\l E ED -I .'l tvl E Da I
225 FIFTH STREET
SPRINGFIELD, OREGON 97477
ENGINEERING DIVISION
oFFlcE TELEPHONE (503) 726-3753
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APPLICATION DATE:
PERMIT NUMBER:
DATE ISSUED:
PHONE
ADDRESS
ATE ZIP:
SUBDIVISION:
ADDRESS:STATE
o<--?ctry
OWNER NE:
)C\
.B
-o
-9311^r-
TAX MAP:
LOT
SITE INFORMATION:
LOCATION
APPL!CANT
REOUESTED PERMITS:
I PROOF OF INSURANCE: $500,000 MINIMUM lF WORK lS DONE BY PROPERWOWNER
El SIDEWALK REPAIR: ......$ 10.00.
(-,(; -(r-c)
fl DRIVEWAY/CURB-CUT/SI DEWALK: .....................
TOTAL DUE WITH PERMIT $
E ADDTTTONAL DRTVEWAY:......$ 30.00
AMMOUNT OF SIDEWALK IN EXCESS OF gOFT @$0.06 sF $ ^t'.fr
'.,..............$ 60.00
CONTRACTOR INFORMATION :
€a.J L c
PHONE
CONTRACTOR REGISTRATION NO
PROJECT SUPERVISOR:
CONTRACTOR
ADDRESS;
EXPIRATION DATE:
PHONE:
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:OO A.M. WILL BE MADE THE
SAME DAY, REOUESTS AFTER 7:00 A,M. WILL BE MADE THE NEXT WORKING DAY. INSPECTIONS ARE TO BE CALLED lN
AFTER EXCAVATIONS ARE MADE AND FORM WORK IS IN PLACE BUT PBIOR TO POURING CONCRETE.
rH E LAN E un LdiE6"ebUHBiflrih ruc co u N cr L's"oNE CALL NUMBER', 1.900-332-2344 \L.L48 I'IOURS BEFORE DIGGING
-uO\--
SIGNATURE:If.
al required.inspeqtions are r.equeste( at the ploper time, tllat project address is readable from theol plans wtll rematn on tne stte at all ttmes dunng construction.
Bv sionature. I state and aqree, that I have carefullv examined the comoleted aoplication and do herebv certifu that all information herein
is'truE and ctlrrect. and I frirther certifu that anv and all work performed shall be'done in accordance wlth the Ordinances of
the Citv of Sorinqfield. aoolicable Citv'Standaril soecificationb and Drawinqs, and the laws of the State of Oreqon oertaininq to the work
descr.i6ed hdreinl I furthbl certify that only contrabtors and employees wh6 are in compliance with ORS 701.055 will be usdd
on this project.
The Citv mav inspect the work site described in this permit at anv time durinq a one vear period followinq the receiot bv the Citv of notict
of combletion of the described work and specifu, at the Citv's sole descressidn, anv Sdditional restoratioi work reoi.rired to retuin the siteto a stgh.dard acceptable to the City. The.pbrmittee will be notified in writing.of any'work required and will have thihy days (30) from the
date-of the notice to corpp.lete the work. Work 4ot completed at the end of Ihe thirty days will be performed by
the City and the costs will be billed to the permittee.
I furthor aoree '
street, and the set
Sig
O
to ensure
DATE PAID
Date ./D ^x -q I
AMOUNT RECEIVED:
RECEIPT NO:RECEIVED BY:
City of Springfield
IVEWAY/SIDEWALK IT AP ICATIONP
I