HomeMy WebLinkAboutPermit Curb Cut 1998-12-30
226 FIFTH STREET
SPRINGFIELD, OREGON 97477
ENGINEERING DIVISION
OFFICE TELEPHONE (603) 728-3763
~
ENCROACHMENT PERMIT
NUMBER:
PERMIT NUMBER: ~ /V tJtb / .'
, i
INSPECTION LINE SEE INSPECTIONS ON BACK SIDE '
APPLICATION DATE:
'.
DATE ISSUED:
,LOCATION OF WORK
APPUCANT \--I-A-'I lI~U ~Df\J\l'3:..
SITE ADDRESS: 1!?1o lOA K I}A-!F 4VF
CITY: 5PR\N~E-LD STATE: OR
SUBDIVISION: H.'\'/"N"".....:, OA-KDA\.E""
OWNER: HA-\l[)E1U F-:t\ \TEQPQ~~c.,. l~l.l" PHONE: e;41-.,4A--lrqloL/\
ADDRESS: .8'?F.~ DllUU()!\....l CITY: 5PR\~ lt1.:Cli::1 D STATE: (")0 ZIP: C\14.:JA.
CONTRACTOR: ~[)FI\\ ~,\)T. ADDRESS: ^"2F,9\ 'P1~~\J(f\"--"t, C;P.. f"\~PH~NE:2.44""'nql.1J
CONTRACTOR REGISTRATION NO: . C!\ZZoe . EXPIRATION.DATE: ....,) cg '1' .
PROJECT SUPERVISOR: M A-TlI\A\I'Y'\"~ PHONE: .::I54-~l.tLo .
J
,PHONE ~1-'''44--1l"l0l101 0
,TAX MAP:
TAX LOT:
ZIP: Cj., 4-"7 .,
REQUESTED PERMITS:
o ENCROACHMENT PERMIT NO: ............................... n
VAUl NllI SIXTY lSOl 0""" PROII 0.\11 0' IllUAHCI
(J CUT STREET (J BORE (J OTHER Q
(J DUST CONTROL (TYPE OF CONTROU
(J CONSTRUCTION. STORAGE. STAGING n
(JO~~ n
(J ASPHALT DEPOSiT............................................................................................................
INSPeCTIONS RlClUUW).
APl'UCATION...,_
ACCOUNT HOI
Q "SO.00
Q'
TYPE OF SFClJRITV OEPOSIT
.9 BLANKET SURETY BOND (J SURlITY BOND Q CASH I CHECK
8'CURB CUT PERMIT N~: .................... FT. Q
INltP~M1.,N. CURl, A~OACH APlIR FORMa ARI WCTIO BUT.'rWH 'ro POURINQ CONCRETI.
, VALlOI'OllIIOO.\""_ O.\l1Ol'IIIUANCL
(J SECOND DRJVEWA v ISEE SEPARATE APPUCA nON!
Q SIDEWALK PERMIT NO:.................... FT.
VAIIHOA tlO DAVS MOM DATI 0' ISIUANCL
(J NEW (J REMOVE I REPAIR Q PAVE PLANT STRIP
(J'SETBACK (J CURBSIDE Q LENGTH
lN~~l"TInl<J, thDfWAu:: IORNfWAV FOR AU CONCftm PAVINQ WITHlN THI STREET NOHT OF WAY, TO 81
MADI AFTER AU EXCAVATlNQ IS CO~, AND PORM WORK AND aUB-BAlI MATlR1AI.IS IN P'L.AC1.
o SANITARY SewER CONNECTION PERMIT: ................ n
YAU) FOR SIXTY (801 DAYS FROM DAn OP ISSUAHCI
Q TO STUB (J MAIN UNE lEASEMENT.R/W) Q OTHER
o STORM SewER CONNECTION PERMIT: .................... n
VALlO 000 IlXTY 1101 0""" PROM 0.\11 DI' IUUANCI
(J CATCH BASIN I BU~ Q STUB Q MAlNUNE
PROOF OF I"'~II"~ '600.000 MINIMUM
. (J ATTACHED (J REQUIRED AMOUNT
O'
O'
O'
O'
J311O.00 + '.161FT.
n
Q .10.00H.161FT.
a $5.00 I .
Q .6.00 I
DESCRIPTION OF PROJECT:
TOTAL Dulii-.
TOTAL DUE WITH PERMIT .
//J /J ()
PERIOD OF USE OR TIME OF CONSTRUCTION:
Q PLANS (TWO SETSI ATTACHED
AREA: LENGTH:
TYPE OF WORK: CUT:
OTHER:
EXISTING SURFACE MATERIAL:
BACKFILL MATERIAL TO BE UTIUZED:
SURFACE REPLACEMeNT MATERIALS TO BE UTILIZED:
TYPE OF OUST CONTROL TO BE UTIIJZEO:
NAME OF OTHER UTILITIES IF THIS IS A JOINT PROJECT:
WARNING DEVICES TO BE UTIUZED:
Advanc..1gnIng end wotk Ion. .protlctlon to blln com~.nc. Wltn tn. Manual on Uniform Tr.UJo Cont1Ol o.vtcu (MUTeD),
FROM DATE:
TO DATE:
.wIDTH:
DEPTH:
. TIME:
TIME:
HEIGHT:
BORE:
. BACKFILL MATERIAL:
DESCRIPTION:
01
WORK SHALL COMPLY WITH CHAPTER X ARTICLE II OF THE CITY CODe, CONTRACTOR TO COMPLY WITH MUTCD .
REVISIONS 1/24181 FORM , 11' '
.
I
PLAN REVIEW COMMENTS I SPECIAL INSTRUCTIONS:
D~it~~~~~~8:I'~A'~.BdW~.~~!i~o:m, EXISTING CITY CODES AN.MPUANCE WITH CURRENT
... . J to.
- 001 Backfill With ll' mlnUl rock. 3 018 Mlnumurn 4' ell.r.nc. It Iny polnt. Iwlng-away.
..
.. 002 Completlvl'" 18'10011 dlpth. 020 Conerll1 minimum 4' dlpth, 3,OOOp.I.
.
.. 003 R.qvlrll complCllon with I Itlll rollllr, . 021 Trench to bl .,.. 0\11.
.. 004 A.C.to mltch thl g'l.tlr 01 Ixlltlng dlpth 0' 4'. . 022 N.ld. Stltl I CountY plrmlt.
.. 005 All OVII .lllld lor flnlllMploilon. . 023 No .bov. ground I"clollngl In ,Ide walk or hlndlcap ramp..
ri 008 . TlmpOfl", pitch ml'( b. u,"d .t1lll Ind 01 thl d.y. . 024 DIamond cut A.C,!Concrttl yalue bOX" to grad..
. 007 Signing Ind Zond protletlon to comply with MUTCO . 026 Frl.h 011 .Ign. I Grldld.
. OOB Cvt oonClltl only on Icorl IInll Or cold lolnll. . 02B COmply wlth Amlrlcln. with Olllbllltll. Act.
. 008 8ldlwalkl Ind drtYlwlYI rnIn. 3,OOOp.~ . 027 Conerl" ""bl, 72h... curing tlml, 4600p.l.
. 010 Curbing mln 3,500p'" No pltchwor1c 1.11 thin 3', . 028 Concrltl .llbl ..qui" lolnl 1111 m.t.rl.l.
. 011 Molt min. requlrtm.nu on curb 0\111. 8pld. codl. . 02B OrlVlwiy nqulttl dowlll IVI", lB'.
012 Rlltore pllntld.'''"'' Spld. codl 20B.3.05 . 030 Submit trltna control plan plior to excavation.
013 Sp"C. to Bo" I Jlck I No A.C. 0\11.. . 031 Notlly Trlmc Olvlllon blfore IXCI.lllpn.
014 M.chenlClI comPleting required. . 032 Cor. drill mlln I1n.. Inllrt tee. 2% min. grad..
015 No pltchwork Inowld. . 033 Mu.t comply wlth thl provl.lonl of ORS 767.641 to 767.571.
01B Lltlrel 0\11110 hoVI ..ntrol dlMIIV fill. . 343 B' C1rcvllr hoII1H2Cl-Vlc.
017 CUI. to bl pOlymlrlZld .rlck 1IIIId lor fln.lln.pectlon. .....
, 01B Mlnlnum 2- crushed rock .. mlnua.
Comment.:
t,
YOU ARE REQUIRED TO CALL
THE LANE UTILITIES COORDINATING COUNCIL'S
"ONE CALL NUMBER" 1-800-332-2344
48 HOURS BEFORE DIGGING
l
INSPECTIONS:
'.(;r-c\lRB cUr AND SIDEWALK INSPECTIONS CAll 728-37B9IRECORDER) STATE YOUR DESIGINATED CITY JOB
NUMBERIPERMIT 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 WOIlK IS IN PLACE BUT PRIOR TO POURING CONCRETE.
CJ SANITARY SEWER, STORM SEWER, ENCROACHMENT PERMIT AND OTHER INSPECTIONS CALL CITY MAINTENANCE AT
728-3781.
SIGNATURE:
/ d-. 130/ 7?i
~O/S ,e;;.-:~
By slgnelurB, I stete Bnd agree~ thet I heve cBrefully exemlned thB completed eppllcetlon and d.o hereby certify thet elllnformetion
herein Is true and corrBct, and further certify thet eny Bnd BII work PBiformed ehBII be dpne In eccordence wllh the Ordinences of the
, City of Springfield, eppllcBblB It'( Standard epeclflCBtlons Bnd Drawlngshand the IBWS Clf the State of Ore.!!on perteining to the work
described herein. I further certify thet .only conlrectors end employees w 0 ere In compllancB with ORS 70) .056 will be used on this
. project.
The City mey Insllect thB work site described In this permit et 'eny \Ime during e one yeer period following lhe receipt by the City 01
notlce of.completlon of the described work and spe<1Lfy, et tho City s sole descresslon, erlY eddlllonel restoretion work'required to
. return the site to a etenderd accepteble t.o the City. The permittee will be notified In writing of eny work required end will hsve thirty
'. deys (30) from the date of the n.otlce to C.omplete the work. Work not completed et the enCl of the thirty deys. will be performed by the
City end the oosts will be blllBd to the permittee.
I furthor egree to ensure thet all required Inspections ere requllsted et the proper time, lhBt project eddress Is reedeble Irom the street.
:::~~;;;;~.."'m.d""",__"" om /ijJvftf
AMOUNT RI;CEIVED:
RECEIPT NO:
/1), {Go
~:? L./(;l7
10
DATE PAID:
RECEIVED BY:
VALIDATION:
o TRAFFIC REVIEWED BY:
o ENGINEERING REVIEWED BY:
o MAINTENANCE:
o PERMIT ISSUED BY:
DATE:
DATE:
DATE:
DATE:
; FOR SIDEWALK AND CURS CUT PERMITS PLACE A COPY (COMPLETED) IN PERMIT DRA WER.
. INSPECTION:
; INSPECTION:
WORK IN PROGRESS
AT TIME OF COMPLETION:
ELEVEN:TH MONTH:
DEPOSIT RETURNED:
DATE:
DATE:
DATE:
DAT~:
DATE:
DATE:
.'