HomeMy WebLinkAboutPermit Sidewalk 1999-10-15
~, Ci1y of Springfield
DRIVEWAY/SIDEWAL PERMIT APPLICATION
225 FIFTH STREET
SPRINGFIELD, OREGON 97477
ENGINEERING DIVISION
OFFICE TELEPHONE (503) 726-3753
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PERMIT NUMBER: qerl 4'2..... ~
DATE ISSUED: )0 ~/~ -er1
APPLICATION DATE:
/I) ~ I s;-- 9"7
SITE INFORMATION: ~.
LOCATION OF WORK: ~/J,~ 11/'1;;111"
APPLICANT vF9/)/I';': r -f /--#/:,;:-l'J
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PHONE
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ADDRESS: ;2J163-
CITY: c::;rr.
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ZIP: ? n75?
TAX MAP:
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STATE: oj{
TAX LOT:
SUBDIVISION:
OWNER:
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PHONE:
ADDRESS:
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CITY:
STATE:
ZIP:
REQUESTED PERMITS:
erDRlVEWA Y ICURB.CUT ISIDEWALK: ......,.............:.......................... .........,............ $ 60,00
AMMOUNT OF SIDEWALK IN EXCESS OF 90FT. @$0.06 SF, $
o SIDEWALK REPAIR: ,..,..........................,..,...............,..................................$10,00.
o ADDITIONAL DRIVEWAY:
..........,.,""',....................,.........................., ,$ 30,00
o PROOF OF INSURANCE' $500,000 MINIMUM IF WORK IS DONE BY PROPERTYOWNER
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.' TOTAL DUE WITH PERMIT $ I/J IJ
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CONTRACTOR INFORMATION:
CONTRACTOR: -;;r;: ~C{ rf' _ !-b)I,LO,":-
ADDRESS: ~("j ~I :;2,q25;t:'S'P~...../1
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CONTRACTOR REGISTRATION NO: f /
PROJECT SUPERVISOR:
PHONE: ?:;It:, ~K"
EXPIRATION DATE: 4/20/~~ '-'
PHONE:
INSPECTIONS:
AN INSPECTION REQUEST SHOULD BE MADE PRIOR TO POURING CONCRETE, AFTER THE PROPOSED WORK HAS BEEN FORMED
AND MADE READY TO POUR.
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CURB CUT AND SIDEWALK INSPECTIONS CALL 726-3769 (RECORDER) 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 WORK is IN PLACE BUT PRIOR TO POURING CONCRETE,
YOU ARE REOUIRED TO CALL
THE LANE UTILITIES ,COORDINATING COUNCIL'S
"ONE CALL NUMBER" 1.800.332.2344
48 HOURS BEFORE DIGGING
SIGNATURE:
I
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AMOUNT RECEIVED: \ / ~ DATE PAID:
RECEIPT NO: S 7 't"9CZ RECEIVED BY: tJ!z"q, IG fflJ-!{c/
By signature, I state and agr~e, that I have carefully exa';'ined the completed application and do hereby cel1ifv'\hat all information herein
is tru~ and correct and I ful1her certify that any and all work performed shall be done in accordance With the Ordinanc~s of
the City of Springfield, applicable City StandarCl specifications and Drawings, and the laws of the State of Ore.!lon p'el1aming to the work
desc~iijed ~erein. I fUl1h~r cel1ify that only contractors and employees who are in compliance with ORS 701.055 will be used
on thiS prolect.
The City may inspect the work site described in this permit at any time during a one year period following the receipt by. the City of noticl
of completion of the described work and speclfv, at the City's sole descression, any addillonal restoration work re~uirea to return the SltL
to a standard acceptable to the City. The permitlee will be notified in writing of any work required and will have thirty days (30) from the
date of the notice to cOf(1plete the work. Work not completed at the end of the thirty days Will be performed by
the City and the costs w!H be billed to the permittee.
I ful1hor agree to ensure tj1at all required inspections are requested at the proper time, that project address is readable from the
street, ana the approved set of plans will remain on the site at all times during construction. '
Signature Q~~ p, e~~
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Date
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