HomeMy WebLinkAboutPermit Miscellaneous 1998-5-18
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226 FIFTH STREET
SPRINGFIELD. OREGON 97477
ENGINEERING DIVISION
OFFICE TELEPHONE (503) 726-3763
~
ENCROACHMENT PERMIT
NUMBER:
PERMIT NUMBER: ~J"?""""~.4
INSPECTION LINE SEE INSPECTIONS ON BACK SIDE '
APPLICATION DATE:
"
DATE ISSUED: ~-/.1e :?i!:::S
"LOCATION OF WORK
APPLICANT _ / """,;t::')C:'- ~ "'" ___
SITE ADDRESS: v -,,'S"-.2 0/' ~/A-"
CITY: ~~ STATE: ~
,
SUBDIVISION:
OWNER: ~,;tyC"" . PHONE:
ADDRESS: :;;j":2 A. ~CITY: ?~ 7") STATE: ~ ~ ZIP: -::r.;:.~-.--.
CONTRACTOR: ~f""'V"~'" ' '1uuRESS; ~527 .:=:,-R //~ :PHONE: /V~.~~.1
CONTRACTOR~EGIS,.'AATI~O; _ ~o.2 - EXPIRATION ,DATE: ~""L/-~ .
PROJECT SUPERVISOR: I'~?f<" :~~..-' PHONE:
,
REQUESTED PERMITS: .....CTIONS RlOUIIW>, Al'l'UCATION FUIOEPOSIT
PHONE ~R~- ?-,:::s--
~;><. .TAXMAP: /?"Y?::?-~/' '"3'/
ZIP: .r::3~?~ TAX LOT:d!:J 2...;~'::>
a ENCROACHMENT PERMIT NO: ............................... n
VAll) FOR SIXTY 1101 DAYS PROM DATI 0' ESIUANCI
Q CUT STREET Q BORE Q OTHER 0
Q DUST CONTROL CTYPE OF CONTROU
Q CONSTRUCTION. STORAGE. STAGING n
QO~~ n
o ASPHALT DEPOSiT...........................................................................................................
TYPE OF SECURITY nEPOSIT
o BLANKET SURETY BOND 0 SURIITY BOND Q CASH I CHECK
ACCOUNT NO:
o $20.00 I
0$
A
}}lr-
;; ~
0$
0$
0$
o CURB CUT PERMIT NO: .................... FT. 0
lH!tlltrM'lnN. CURB I APPROACH AfT!R FORMS ARI ERECTID BUT PRIOR TO POURIHO CONCRm.
, VAll) FOR too DAn FROM DATI 0' ISSUANCE.
o sEcoNii DRJVEWA Y CSEE SEPARATE APPUCA nON)
o SIDEWALK PERMIT NO:.................... FT. n
VAll) 'OR 110 DAYS MOM DATI 0' ISSUANCI.
o NEW 0 REMOVE I REPAIR 0 PAVE PLANT STRIP
o 'SETBACK 0 CURBSIDE 0 LENGTH
."'!1:Hl'"Tlnt.l. ltIDEWAlK I DRIVEWAY FOR ALL CONCRITI 'AVtNQ WITHIN THE STRm NOHT OF WAY, TO BE
MADE AFTER AU EXCAVATINQ ts COMlUTI, AND FORM.WORK AND SUB-BASI MATIRIAL as IN PLACE.
a SANITARY SEWER CONNECTION PERMIT: ................ n
VALID FOR SIXTY lSOJ DAYS FROM DATE 0.: tSSUAHCI
Cl TO STUB 0 MAIN UNE lEASEMENT-R/W) 0 OTHER
~ STORM SEWER CONNECTION PERMIT: ....................n
VALl) PeR SIXTY 1101 CAva fROM DATI OP ISSUAHCI
o CATCH BASIN , BUIlllU!R 0 STUB 0 MAINUNE
PROOF (Ie ....c,,'''~ $600.000 MINIMUM
, 0 ATTACHEO 0 REQUIRED AMOUNT
0$
o $10.00H.16IFT.
o $10.00H.15IFT.
. 0 $5.dO I '
"fI $5.00 I
.o:;;~
DESCRIPTION OF PROJECT:
TOTAL Duei-.
TOTAL DUE WITH PERMIT $
q.. -z:,.
PERIOD OF USE OR TIME OF CONSTRUCTION:
, 0 PLANS (TWO SETS) ATTACHED
AREA: LENGTH:
TYPE OF WORK: CUT:
OTHER:
EXISTING SURFACE MATERIAL:
BACKFILL MATERIAL TO BE UTILIZED:
SURFACE REPLACEM'ENT MATERIALS TO BE UTILIZED:
TYPE OF DUST CONTROL TO BE UTI~IZED:
NAME OF OTHER UTILITIES IF THIS IS A JOINT PROJECT:
WARNING DEVICES TO BE UTILIZED: '" , .,
Adnnc. signing Ind work Ion. .prot.ctlon to b.," oornp!l.nc. Wl~" tn. M.nu.l ~.Unl'orm TreUte Contror C'vlo.. (MUTeDJ,
FROM DATE:
TO DATE:
WIDTH:
DEPTH:
TIME:
, TIME:
HEIGHT:
BORE:
, BACKFILL MATERIAL:
DESCRIPTION,
..
WORK SHALL COMPI.Y WITH CHAPTER X ARTICLE IS OF THE CITY CODE. CONTRACTOR TO COMPLY WITH MUTCD .
REVISIONS' 8/24/85 fORM , 111 '
,
,
PLAN REVIEW COMMENTS I SPE~NSTRUcnONS: ' ...
RESTORAnON WORK SHALL BE IN CONFWANCE WITH EXlSnNO CITY CODES AND _MPUANCE WITH CURRENT
STANDARD SPECIFICAnONS. EXCEPT AS NOTED BELOW.
001 IlIcklUl With '" mln.. rock. - 018 M1numum 4' clurlnCllllny point. Iwing-IwIY,
o .
o 002 Complct 1.lry IS" 10011 dlpth. . 020 Concrlll minimum 4" dlpth. 3.000p11,
o 003 Rlqulrll complotion with I I1III rol1llr. . 021 Tllnch 10 be .,." out.
o 004 A.C.lo mltch thl grlltlr ollxllllng dlpth or 4". . 022, Nlldl Stili I Counly plrmlt.
o 005 All CUIIIIIIId 10' 1lnIllnoplotion. . 023 No IbovI ground Incloll~lln IldlWllk or hlndlcap rlmpa.
. 008. TtmpOtlry pitch mey b, ulld It the end of thl day. _ 024 Diamond cut A.C,lConer,t. value box,. to grad..
. 007 Signing Ind Zonll p,otletlon to comply with MUTCO _ 025 F'lah 011 IIgnl I Oradld.
. 008 Cut coneret. only on .cor. IIn.. or. cold lolntl. . 028 Comply wlth Am.rlcan. with Olllblllties Act.
008 Sldlwllke Ind drtVIWIYI inln. 3.000p1~ 027 Concrlll IIlbl, 72ht.. cUllng Ilml. 4500pal.
: 010 Curbing mln 3.800p1l1 No pllchwortdl" thin 3'. ~ 028 Concrllllllblllqulrl lolnllul metlrill.
. 011 MI.I min. IIqulramlnll on cur\) CUll. Spld. codl. 028 Orlvlwey llqultel dOWIII 1.lry 18".
. 012 Rlltorl pllntld,IIIU. Spld. Codl 20S.3.05 030 Submit trllllo control plln prio, to I.cavltlon,
_ 013 SpIC. 10 e01l1 Jlck I No A.C. outa. ' _ 031 NotllY Trlmo DI.lalon bllo'II.CI.ltlpn.
014 Mlchlnlcel comPleting IIqv~ld. 032 Corl drill meln IInl. 1nI1" III. 2~ min. grlda.
. ,0
. 015 No pelchworlt IlIowld. . 033 M..t comply With Ihl pro.lllonl 01 ORS 757.641 to 757.671,
. 01S Lellral outalo hl.1 control dlnollY fill; , 0 343 S" Circuli' holl/H2a-Vlc.
017 Cutalo be polymlrized crack 1IIIId lor flnlllnaplcllon.
c.. ' 018 Mlnlnum 2- crushed rock ". minus.
.. ..~.
~
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Commenls:
t,
YOU ARE REQUIRED TO CALL
THE LANE UTILITIES COORDINATING COUNCIL'S
"ONE CALL NUMBER" 1-800-332-2344
48 HOURS BEFORE DIGGING
INSPECTIONS:
'Q
CURB CUT AND SIDEWALK INSPECnONS CALL 728-3789 (RECORDER) STATE YOUR DESIGINATED CITY JOB
NUMBERlPERMIT NUMBER. JOB ADDRESS, TYPE OF INSPECTION REQUESTED, AND WHEN YOU WILL BE READY FOR
INSPECTION, CONTRACTOR'S OR OWNER'S NAME AND PHONE NUMBER. REQUESTS RECEIVED BEFORE 7:00 A.M. WILL BE
MADE THE SAME DAY, REQUESTS AFTER 7:00 A.M. WILL BE MADE THE NEXT WORKING DAY. INSPECTIONS ARE TO BE
CALLED IN AFTER EXCAVATIONS ARE MADE AND FORM WOFjK IS IN PLACE BUT PRIOR TO POURING CONCRETE,
o SANITARY SEWER, STORM SEWER, ENCROACHMENT PERMIT AND OTHER INSPECTIONS CALL CITY MAINTENANCE AT
728-3781.
SIGNATURE:
io
~-/$~.g
~~
//
AMOUNT RECEIVED:
RECEIPT NO:
~.t:>~
?~~8~
DATE PAID:
RECEIVED BY:
By signature, I stete and agraa, thst I hava carefully nxemlned tha completed application and do hernby cnrtify thsl all information '
heraln Is true end correct, end further Qertlfy thet eny end ell work pei/ormed shsll be done In eccordence WIth Ihe Ordinsnces of Ihe
City of Springfield, eppllceble City Stenderd speclflcetlons end Drewlngshand the laws of the State of OreJl~on perteinlng 10 Ihe work
described herein. I further certify Ihat only contraclors nnd employees w 0 are In compliance with ORS 701.055 will be used on Ihis
, project.
The City mey Insllect the work site described In thil I!ermit el 'eny time during e one year period following the receipt by the City of
notice of,completlon of the described work end apec:Lfy, et tho' City's sole descresalon. eny eddltional restoration work're~uired to
, return the aile to a slandard ecceptable to the City. The permittee will be notified In writing of any work required and will hs.e thirty
" daYs (30) from the dete of the notice to co",plete the work. Work not compleled al the enCl of Ihe Ihlrty days'will be performed by the
City and the costa will be billad to the permittee.
I furthor agree to ensure that ell required Inspections ere requdsted et Ihe proper lime, thet project eddresa Is readable from the straet.
end the approved set of plans will remeln on the site et alllomes during construction.
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Slgnature~ ,,~~.~~~ Date < I,~ {or~
VALlDATION:'l ..
o TRAFFIC REVIEWED BY: DATE:
o ENGINEERING REVIEWED BY: DATE:
'0 MAINTENANCE: DATE:
o PERMIT ISSUED BY: DATE:
J
; FOR SIDEWALK AND CURB CUT PERMITS PLACE A COPY (COMPLETED) IN PERMIT ORA WER.
, INSPECTION:
" INSPECTION:
WORK IN PROGRESS
AT nME OF COMPLETION:
ELEVENTH MONTH:
DEPOSIT RETURNED:
,DATE:
DATE:
DATE:
DAT~:
DATE:
DATE:
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