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SPRINGFIELE,
225 NORTH FIFII] gTFEET
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TN9PECTIO?.I LINE: 126-3163
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gECCtlD DRI\EIUAY ( gEE TRAFFIC )
REaUIRE9 AFPLICATIOIi FoR A 5E@ND DRt\€rUAy(T-4.1a)
OR A COTJNTY APPLICATIOI.{ FOR FACILITY PERI1IT (C AO.2O3)IF IN THE U6.8.
DATE OF AFPLICATICT.I *-/-'rz
RECEIPT NO:
C49'11
{7 76
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CHECi<ED rcR DEL IN6YJENC IEg
SIGNED:
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FFOCEDLIFE FOR IN9FECTICT{ RE@IIEST:
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CALL 12b-3163 (RECORDER ) 9TATE YOTJR CITY DE9IGNATED JOts NUrE=R, JOg ADDRES5,TYPE OFlNgPEcrlot{ REauEsrED A{D tlF{EN YotJ tulLL BE €Atiro{ rNspEcrto}l, ca.{TRAcroRg oR orrNERg N4t 1E AIDPlloNE NtfltsER REauEsTg RECEI\GD BEFoFE 1t@o *l tUlLL EE F1ADE Tt-.lE SAtlE DAy, REaJEsTg zf;rr:R 1zo@A}.l I!,ILL BE I1ADE THE NEXT IIJORKI}.IG DAY
BtJILDIN6 NO. ( IF APTL ICABLE )
*YOI,JR CITY DEgIG*.IA ,TED JOB NO.l3f q 2- ,la2 ('*-czgEE tsOOK
REAUIRED IN9PECTIOI{9 v
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OF UJALK
9IDEII,IALK / DRI\GUAY
FOR ALL CONCRETE PAVING IUITHIN
TI{E STREET RIGHT OF IUAY, TO BEI,IADE AFTER ALL EXCAVATTNA
15 COIIPLETE r'ND FORI1 TUORKAID gUB.BASE IIATERIAL 19
IN PLACE
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rlO.OO+*@.15/LF.(X)
CURB / APPROACH APRo,i{:
AFTER rc819 AE EREC'JED
tsUT PRIOR TO Po'URNG
CONCRETE.
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FE,E9:
TOTA FEffllT FEE,,/-(./c
COi.II.IERICAL DRI\€II.'AYg s+.]ALLHA'G, >'TO A'FLAIRS3'. O- gTA\DARD
I i]A\€ CARERILLY EXAJ-1INED TI-.IE COF1PLETED APPL ICATIOhI FOR PER-'ilT, AND DO HER=By CERT,Fy THr,T ALLINTRHATIOhI HEREON 15 TRL,IE AI{D CORRECT, AI.ID I FuRTI{ER C=RTIFY THAT ANY AND ALL UPR<PEFOR1ED5}.]ALL BE D4IE IN ACCORDANCE [UITH TllE ORDINANCE9 OF Tr..t=C|TY G 9PRING'FI ELD, AND Ti]E LAUS OF TIJEgTATE OF OREGON PERTAINING T o Tt{= UJoRK DESCR|B=D +.1==IN, A\D Ti..,IAT NO OCCUPA\CY UiLL 3E IIAD=G AIY STRJCTRE UITi]OIJT PEB1I9SION OF TI]E BUILDING Dtvrglo\l I FuRTi..lERANDEIIPLOrEES U,J+-IO CERTIFY TIIAT ONLY CONTRACTORS
TI.]I9 PROJECT.
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rN col'IPLtANCE rutTl.{ oRS 1 oto>5 UJILL BE Us=D ON
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