HomeMy WebLinkAboutPermit Encroachment 1999-04-23I
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STATE:ZIP:TAX LOT:
SUBDIVISION
OWNER
tHADDRESS
CONTRACTOR:ADDRESS:
EXPIRATION DATE
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APPLICATION DATE:DATE ISSUED:
SITE ADDRESS:
CITY
LOCATION OF WORK
APPLICANT
CONTRACTOR REGISTRATION NO:
PROJECT SUPERVISOR:
225 FIFTH STREET
SPBINGFIELD, OREGON 97477
ENGINEERING DIVISION
OFFICE TELEPHONE (503) 726.37
ENCROACHMENT PERMI NUMBER:
SrArE: Oe ,rr,QHOl
REOUESTED PERMITS:INSPECTIONS REOUIBED: APPLICATION FEE / DEPOSIT ACCOUNT NO:
E AsPHALT DEPosrr.......... $
E rype or sEcunrv oeposrr For:
E BLANKET suRETy BoND E suRttrY BoND E cASH / cHEcK $
E SAi{tTARy SEWER CONNECTION:...... E MAIN LINE (EASEMENT-R/w) E ro sruB E orHER
E STORM SEWER CONNECTION: tr cArcH BASIN / BUBBLER E sruB E MATNLTNE
I pRooF oF INSURANCE: $500,000 MINIMUM E ATTACHED E ADDIIoNAL REoUIRED AMouNr
fl ervcnoacHMENT PERMTT No:$80.00 /
DATE OF ISSUANCE
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(60) DAYSJROM
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TOTAL DUE WITH PERMIT $
E OTHER
E OTHER
VALID FOR SIXTY
E CUT STREET
E DUSr CONTROL (TYPE OF CONTROL)
E CONSTRUCTTON, STORAGE, STAGTNG
DESCRIPTION OF PROJECT:
CiE of dpringlheld e
NT PERMIT APPLICATIONNCROAC
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PERIOD OF USE OR TIME OF CONSTRUCTION:
tr PLANS (TWO SETS) ATTACHED
FROM DATE:
TO DATE:
TIME:
TIME:
AREA: LENGTH:WIDTH DEPTH:HEIGHT:
OTHER:
BACKFILL MATERIAL TO BE UTILIZED:
SURFACE REPLACEMENT MATERIALS TO BE UTILIZED
TYPE OF DUST CONTROL TO BE UTILIZED:
NAME OF OTHER UTILITIES IF THIS IS A JOINT PROJECT:
WARNING DEVICES TO BE UTILIZED:
Advance signing and work zone protection to be in compliance with the Manual on Unilorm Traffic Control Devices (M
DESCRIPTION
SHALL COMPLY W$H GHAPTEB X ARTICLE 5 OF CONTRACTOR
REvlsloNS 3/29/99 FOBM # 116
WORK
THE GITY CODE TO COMPLY WITH MUTCD .
,
CITY:
TYPE OF WORK; CUT: BORE:
EXISTING SURFACE MATERIAL: BACKFILL MATERIAL:
PLAN REVIEW COMMENTS /INSTRUCTIONS:
RESTORATION WORK SHALL BE lN u .TFORMANCE WITH
STAruDAnDEPEclFtcATloNS, ExcEPT AS NorED BELow.
EXISTING CITY CODES AND IN COMPLIANCE WITH CURRENT
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Backfill with l(" minus rock.
Compact every 1 8" loose dePth.
Requires compaction with a steel rolller'
A.C. to match the greater of existing depth or 4".
All cuts sealed for final inspection.
Temporary patch may be used at the end of the day.
Signing and Zone proteotlon to comply with MUTCD
Cut conctete only on score lines or cold ioints'
Sidewalks and driveways min. 3,OOOpsi.
Curbing min 3,SOOpsi / No patchwork less than 3'.
M€et min, rsquir€ment8 on curb cutg, Spfd. code.
Restore planted areas, Spfd. code 206.3.05
Spec. to Bore / Jack / No A.C. cuts.
Mechanical compacting required.
No patchwork allowed.
Lateral cuts to have control density fill.
Cuts to be polymerized crack sealed for final inspection.
Mininum 2" crushed rock 7." minus.
Minumum 4' clearance at any point, swing-away.
Concrete minimum 4" depth, 3,OOOpsi.
Trench to be "T" cut.
Needs State / County permit'
No above ground enclosings in sidewalk or handicap ramps'
Diamond cut A.C./Concrete value boxes to grade.
Fresh Oil signs / Graded.
Comply wlth Amcrlcanr wlth Dltabllitic! Act,
Concrete slabs, 72hrs. curing time, 4500psi'
Concrete slabs require joint seal material.
Driveway tcquirrs dowela evcry 18".
Submit traffic control plan prior to excavation.
Notify Traffic Division before excavation.
Core drill main line, insert tee, 2% min. grade.
Must comply with the provisions of ORS 757.541 to
571 .
6" Circular hole/H2O-Vac.
Comments:
YOU ARE REOUIRED TO CALL
THE LANE UTILITIES COORDINATING COI..TNCIL'S
"oNE CALL NUMBER" 1-800-332-2344
48 HOURS BEFORE DIGGING
INSPECTIONS:
tr cuRB cuT AND STDEWALK 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: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,
E SANITARY SEWER, STORM SEWER, ENCROACHMENT PERMTT AND OTHER INSPECTIONS CALL CITY MAINTENANCE AT
726-3761.
SIGNATURE:
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AMouNT RECETVED: {0 DArE PAID:
By signature, I state and agree, that I have carefully examined the completed application and do herebv certifv that all information
herein is_ true and correct, and I further certify that'any and all work peiformed'shall be done in accordance with the Ordinances of theCity of Springfield, applicable City Standard Specifications and Drawinqs. and the laws of the State of Oreoon oeifjinlno io the-work -
described herein. lfurther certify'that only cohtractors and employees-who are in compliance with ORS 7d1 ,055 will bdused on thisproject.
The City-may inspect t!"re work site described in this permit at any time durinq a one vear oeriod followino the receiot bv the Citv ofnotice of co.mpletion of the.described work and_specjfy, at the City's sole de5cressioi, anii iOOitionat resioiaiion-wbi[lei-uirei-io-return -the site to a standald.acceptable to the City. The permittee'will be notified in wriiinlq oi-env work-ieoulrea anrj witl6ii,TJ ttiirt,,{avs (30} from the date of the notice to complete'the work. woik not comptetea Ji irrij-en"a ot tli6 inirtv'o-iiJi^iitiljE pijiiori"Ea'tjv tr,City and the costs will be billed to the permittee.
I furthor aqree to ensure that all required insoections are requested at the proper time, that project address is readable from the street,and the ap-proved set of plans wllf i'emain oiitrrri iiie;t;it iimJs. duiing constructron.
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Signature Date
tH o ogtLg)RECEIPT NO RECEIVED BY
VALIDATION:
FOR SIDEWALK AND CURB CTIT PERMITS PLACE A COPY (COMPLETED) IN PERMIT DRAWER.
DATE:
TE:
DATE
E TRAFFIC REVIEWED BY DATE
E PERMIT ISSUED BY
WORK IN PROGRESS
DATE:
INSPECTION:
INSPECTION:
DATE:
AT TIME OF COMPLETION
ELEVENTH MONTH:
DATE:
E ENGINEERING REVIEWED BY
E MAINTENANCE:
DATE:
DATE: