HomeMy WebLinkAboutPermit Curb Cut 1998-12-30
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226 FIFTH STREET
SPRINGFIELD, OREGON 97477
ENGINEERING DIVISION
OFFICE TELEPHONE (503) 726-3753
~
ENCROACHMENT PERMIT
NUMBER:
PERMIT NUMBER: 57ft) 1;2CJ .
INSPECTION LINE SEE INSPECTIONS ON BACK SIDE .
APPLICATION DATE:
'.
DATE ISSUED:
,LOCATION OF WORK
APPLICANT V hi.a.0?l!'u /,bm,IC..
SITE ADDRESS: )( ~5'" ()A-l<'\)~ AVF.
CITY: SPRll/bP6.J;::JSTATE: ()il ZIP: q74:lJ
SUBDIVISIONd I If) V l'\"::1, I r~hrll;-;;}., ii OA-k:DAl F
OWNER: '( HA'Jf)'El\l ~J\'T1='RO~lc...~~, I~\C. . PHONE: C;4-I-,44-ld"r "
ADDRESS: e,2~ PI"UJ,O.h.' CITY: <=;PQI"-lhAELD STATE: OQ ZIP: q"}t4,<P.
CONTRACTOR: K\-tA;'JOFI'J ~ADDRESS:.3ZS~ \)It-..b.1l'\kJ. SPQ\t.,-\t;1=- PH~NE: ~
CONTRACTOR REGISTRATION NO: )( '177..0'0 EXPIRATION. DATE: x' ,-q q
,
PROJECT SUPERVISOR: M IA--rr "" l"'I'" ~
.PHONE
]
541-~[.-~::'~ 144...;.(r?QI'jlJ2...
.TAX MAP: ")(
TAX LOT: v
REQUESTED PERMITS~
PHONE: ,)(/,#-td=ll",r ...
o ENCROACHMENT PERMIT NO: .....,......................:.. n
VAllO FOR SIXTY lSOl 'AVS PAO" DATI OIIIIUANCI
o CUT STREET 0 BORE 0 OTHER n
o DUST CONTROL (TYPE OP CONTROU
INSl"!CTIONs RlCUlJW)1 APf'UC:AT1OH m I 0V08If
ACCOUNT NOI
.
Q ho.o~
Q$
o CONSTRUCTION. STORAGe, STAGING n
OO~~ n
o ASPHALT DEPOSiT...............................................................................,.....................,.....
:rvl>~ nF SECIJRITY DEPOSIT
.JJ.el.AHKET SURETY BOND 0 SURlITY BOND 0 CASH I CHECK
E::("CURB CUT PERMIT NO: .................... FT. Q
IN!tJII~l'"'nft"'. ctJRI 'A'PROACH AFTER fOAMS ARe WCTlD IUT I"IUOR TO POURIHQ CONCRnL
. VALIOFOA11ODAVlflIOfol OATlOIIISUAHC!.
o SECOND DRJVEWA v (SEE SEPARATe APPUCA nON!
o SIDEWALK PERMIT NO: .................... FT.
VAll) FOR 110 DAY' MOM DATI 0' ISIUANCL
o NEW 0 REMOVE I REPAIR 0 PAVE PlANT STRIP
O'SETBACK 0 CURBSIOE 0 LENGTH
'N"=:..,,t"TlnJ<J. lillDfWALK I DRNfWAV fIOR AU. CONCRm 'AVlNQ WITHIN TH! STRUT RJQHT Of WAV. TO 81
MADI AnEA AU IXCAVATlNQ IS COMPUTE. AND FORM WORK AND IUa-BAlI MATIRIAL IS tN f'l.ACE.
o SANITARY SEWER CONNECTION PERMIT: ................ n
VALl) R)A IIXTY llOJ DAYS FROM DATI OP' IIIUAHCI
o TO STUa 0 MAIN UNE (EASEMENT.RIWl 0 OTHER
o STORM SewER CONNECTION PERMIT: ....................n
VALID PO" IlXTV llOJ DAV' MOM DATI 011 tllUANCI
o CATCH BASIN' auSSLER Q STUB 0 MAINUNE
pRnn" /"I~ INSIIRANC~' $600.000 MINIMUM
. 0 ATTACHED 0 REQUIRED AMOUNT
0$
Q$
0$
Q$
Q $10.00+t.15/FT.
n
Q $10.00:+t.15/FT.
Q $6.00/.
Q .5.00 1
TOTAL DUEi-.
TOTAL DUE WITH PERMIT .
//) of)
DESCRIPTION OF PROJECT:
PERIOD OF USE OR TIME OF CONSTRUCTION:
o PLANS (TWO SETS) ATTACHED
AREA: LENGTH: .
TYPE OF WORK: CUT:
OTHER:
EXISTING SURFACE MATERIAL:
BACKFILL MATERIAL TO BE UTIUZED:
SURFACE REPLACEM'eNT MATERIALS TO BE UTILIZED:
TYPE OF DUST CONTROL TO BE UTI!JZED:
NAME OF OTHER UTILITIES IF THIS IS A JOINT PROJECT:
WARNING DEVICES TO BE UTILIZED:
Adv.nce IlgnIng .nd work lone ,protection to b.1n compU.nc. ~n\ the Manu.. on Uniform T,,&no Control D.vlc.. (MUTeD),
FROM DATE:
TO DATE:
.wIDTH:
DEPTH:
. TIME:
TIME:
HEIGHT:
.. ',.~ ~ ,
BORE:
BACKFILL MATERIAL:
DESCRIPTION:
~
WORK r.HALL COMPLY WITH CHAPTER X ARTICLE Ii OF THE CITY CODE. CONTRACTOR TO COMPLY WITH MUTCD .
. MVlSIONS 8/24/1& fORM 1\1' '
.
"
PLAN REVIEW COMMENTS I SPECIAL INSTRUCTIONS: - .. ~ -
~,it~'}fA~~~~m'6<A'~.BMf~A1mC:Em. EXISTING CITY CODES AN.MPUANCE WITH CURRENT
~ 001 IlIckllU WIth S' minus rock. . 018 Mlnumum 4' clursnc. 11 .ny point; Iwlng..w.y.
:.. 002 Comp.et lV.ry IS' 10011 d.pth. . 020 Concr.tI minimum 4' d.pth, 3,OOOpsl.
_ 003 R.qul"lOomp.otIon with utili rolll... . 021 T"nch 10 b. "T" cut.
. 004 A,C.IO milch tho grut.. 01 .xllllng d.pth or 4', 022. Nllds StOll I COUnlY permll,
. 008 All OUtIlllled lor nrillllllplot1on, ? 023 No .bov. ground .ncloslng. In sldewllk or hlndlclp rlmps.
. 008. Temporary pilch may b. used II tho Ind ollhe dlY. :J 024 Dllmond CUl A.CJConc"t. vllu. boxlI to grId..
. 007 Signing Ind ZOM prolletlon 10 comply with MUTCO . 026 F"sh on Ilgnsl Grldld.
. 008 Cui concr.t. only on sco" Ilnll or. cold lolnll. . 028 Comply with Am..lclns with OlssblllUII Act.
. 008 SldlwllkI Ind drtVlwlYI mln. 3,OOOpsL . 027 ConCIIII s1lbl, 72hrs. cuMg 11m., 4600psl.
010 CUrbing mln 3,BOOpsll No ptlchwort Ie.. th.n 3', . 028. ConClltl slsbl rsqulrslolnt lul mltl~sl.
r1 011 Meel min. rsqulrsm.nll on curb CUll, Spld. code. . 028 D~v.way rsquirss dowllslv,ry IS'.
J 012 Risto" pl"nt.d."""s, Spld. cod. 208.3.06 030 Submit \r11l10 control plln prlor to "cS.ltlon,
. 013 Sp.c. 10 SO" I Jeck I No A.C. CUls. C 03 I Notllv Trlll1c Olvlolon b.lo" "clvltlpn.
014 M.chanlcsl compeetlng required. . 032 Core drill mlln line, Inll" tu, 2% min. grId..
r'" 018 No pOlchwork Inowed. 033 Must comply with Ihe provlelons cl ORS 767.641 to 767,671.
3 018 LAle,,1 CUlsIO haVI oontrol delllllV nn. : 343 8' Clrcullr horeIH20.vlc.
017 CUlSIO be polyme~zod creck 1.II.d lor lInsllnsp.etlon. U .
.018 Mlnlnurn 2' crush.d rock S' minus.
Comments:
t.
YOU ARE REQUIRED TO CALL
THE LANE UTILITIES COORDINATING COUNCIL'S
"ONE CALL NUMBER" 1..800-332-2344
48 HOURS 8EFORE DIGGING
INSPECTIQNS:
'~RB cUr AND 81DEWALK INSPECTIONS CALL 728-3789IRECORDERI STATE YOUR DESIGINATED CITY JOB
NUMBER/PERMIT 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 WO~K 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:
AMOUNT RECEIVED:
RECEIPT NO:
/0 < 00
~;:? c::tGL g
To
DATE PAID:
RECEIVED BY:
/2 /g; /7J
.h/~~
l
By Ilgnatura, I Itate end egree~ thet I have carefully examIned the completed application and do hereby certify that all Information
herein Is ~e and correct, and further certify that any and all work parformed shall be d!lne In accordance With the Ordinances of the
. City of Sp ngfleld, applicable Ity Stlndard speclflcatlons and Drawlngshand the lawa !If tha State of Ore1l0n pertaining to tha work
described ereln, I further certify that only contractors and employees w 0 are In compliance with ORS 7<J1.055 will be used on this
. project.
The City may Insllact the work site described In thIs lIarmlt It:any ~Ime during a one year period following the receipt ~y the City of
notice QI.completlon of the delcrlbed work Ind ,peolfy, at the City I lote descrellion, any additional reltoration work required to
. retum th, ,Ite to a standard acceptable to the City. THe PelTl'llttee will be notllled In writing 01 Iny work required Ind will have thirty
. daYI 130'th1rom the dafe ofb tthe Jlolll:ll to COmplete the work. Work not completed at the enCl of the thirty dlYI. will be performed by the
.' CItY Ind e oosll wll be ,lIIed to the permlttea,
I furthor agree to ensure that all rrqulrad Inlpectlons are requllsted at the prol>ar time, that project address Is readabla from the street,
and the approved set 01 pllns wit remain on the lite at all t,mel during construction.
Slg~ature y ~O/#?tII6-. Date >2/so"8
1
VALIDATION:
o TRAFFIC REVIEWED BY:
o ENGINEERING REVIEWED BY:
o MAINTENANCE:
o PERMIT ISSUED BY:
DATE:
DATE:
DATE:
DATE:
I
, FOR SIDEWALK AND CURS CUT PERMITS PLACE A COPY (COMPLETED) IN PERMIT ORA WER.
, INSPECTION:
:. INSPECTION:
WORK IN PROGRESS
AT TIME OF COMPLETION:
ELEVEN:TH MONTH:
DEPOSIT RETURNED:
DATE:
DATE:
DATE:
DAT~:
DATE:
DATE:
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