HomeMy WebLinkAboutPermit Encroachment 2007-6-21
225 FIFTH STREET SPRINGFIELD ~
SPRINGFIELD, OREGON 97477 -A" _
ENGINEERING DIVISION _
OFFICE TELEPHONE (503) 726-3753 ..IlL:.:: ~
APPLICATION DATE: tJ{Q /7-./ /0=1-
I I
PERMIT NUMBER: COM WO=J-- (5,f)C(,q
DATE ISSUED: tJu/z./lo=l-
I ,
SITE INFORMATION:
LOCATION OF WORK: :/ 3 ~ ~ /t:-~ <:S,
APPLICANT QtP~~ ~OO~~_
ADDRESS 90 s)'? &.c::> k (JfLo-
CITY: G~ c;.
.5'?~/,;:)~?L~t? e>~,
PHONE 7~~.-Z79/
TAX MAP:
STATE:
c:>te
ZIP: 9' J lfC~ 2-
TAX LOT:
SUBDIVISION:
OWNER
ADDRESS
PHONE:
CITY
STATE:
ZIP:
)
x ,......................$ 80.00............... = $
o MULTIPLE PERMIT DISCOUNT EA: ........, (MAX 2) .................,.........$ 30,00. ......,.................. =$-'_
(MULTI PERMIT DISCOUNT GOOD FOR ONE SITE AND ONE SITE INSPECTION JlliLY
APPLIES TO 2nd AND 3rd PERMITS ONLY. NOT SIDEWALK REPAIRl
TOTAL DUE WITH PERMIT $ / (). OD
o PROOF OF INSURANCE: $500,000 MINIMUM IF WORK IS DONE BY PROPERTYOWNER
CONTRACTOR INFORMATION:
CONTRACTOR:
ADDRESS:
CONTRACTOR REGISTRATION NO:
PROJECT SUPERVISOR:
PHONE:
, EXPIRATION DATE:
I""
PHONE:
INSPECTIONS:
'j
AN INSPECTION REQUEST SHOULD BE MADE PRIOR TO PQURING CONCRETE, AFTER THE PROPOSED WORK HAS BEEN FO RMED AND MADE READY TO
POUR, CURB CUT AND SIDEWALK 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 INS PECTION, CONTRACTOR'S OR
OWNER'S NAME AND PHONE NUMBER, REQUESTS RECEIVED BEFORE 7:00 AM WILL BE MADE THE
SAME DAY, REQUESTS AFTER 700 AM, 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
llONE CALL NUMBER" 1-800-332-2344
48 HOURS BEFORE DIGGING
SIGNATURE:
AMOUNT RECEIVED $1 fJ , f) 0
RECEIPT NO: ~ qq "c:;
DATEPAlD O}/2.iO=f
, RECEIVED BY: ,fr 11 e m a V'\
By signature, I state and agree, that I have carefully examined the completed application and do he reby certify that all information herein is true
and correct and I further certifY thai any and all work Rerformed shall be done in accordance with the Ordinances of
the City of Springfield, applicaole City Standard specifications and Drawings, and the laws of Ihe State of Oregon pertaining to the work described herein, I further
certify fhat .only contraclors and employees who are in compliance with ORS 701,055 Will be used
on thiS project.
The City may inspect the work site described in this permit at any time during a one year period fo 1I0wing the receipt by the City of notice of COm~letiOn of the
described work and specify, at the City's sole discretion, any additional restoration work reqUIred to return the site to a standard acceptable to the Ci ,The
pernurtee will be notified in writing of any work required and will have thirty days (30) trom the date of tile notice to complete the work. Work not comp eted at the end
of the thirty days will be performed by the City and the costs will be billed to the permillee,
that all reqUIred Inspectl are requested at the proper time, that prol ect address IS readable from the
of plans will remain on le site at all tunes durrng construction,
6-);_ d~ A ~ Dm' 0": 2-/- 07
Signature