The URL can be used to link to this page

Home My WebLink AboutApplication APPLICANT 8/27/2010 . . ihlui lL:L11...! ~.:t t...... .~ LANE COUNTY DEPARTMENT OF PUBLIC WORKS APPLICATION FOR FACILITY PERMIT For Office Use Only DATE: INCOMPLETE APPLlCA nONS WILL NOT BE ACCEPTED SEE PAGE 2 FOR INSTRUCTIONS ANO FEES ALL PLANS MUST BE 11x17 OR SMALLER UNLESS AN ELECTRONIC COPYIS PROVIDED PERMIT#-: 01. 1'1" ~~....t:- PROPERTY OWNER: Print Name (if different from Applicant) lP) I (,,11.1 A-.A! Mailing Address: Street P'.ddress e\1~~ ,,. "l,*D4 City, Slate, Zip Code .-- . . !Ml-~'Z.!l-1 Daytime Phone (Required) (1) ~~ ,. ~u(, APPLICANT: Print Name ICj"\ ~\(,"II/ /W{s Mailing ,o,ddress: Street Address 6)(;~G <>," 011*01 City, State, Zip Code , c::4kl4Z' O(p \; ~hone (Required) "m(--$lo-40t;1l ~hone Cell Phone, ~...I"E14 G "1.c?,J -(Q\ E-mail Address E-mail Address (2) Road name V\Jt,~Iy,.IP'1 (3) ~AP-TAXLOT~ ~?nge ~ J.?ction jl~~t (4) Street address (if not addressed put N/A) ~ \ c; . Approximate Mile Post of Road 0.1>'5 (5) Nearest Town ~I,.J'?IE'L!? (6) Direction-s to site from nearest major cross road ~....U::,"".JLl ~1,..VO ~ t11~ l~ · pi I FAX FAX Evening Phone Cell Phone (7) CHECK ONE BOX BELOW THAT BEST DESCRJ/?ES THE WORK YOU PLAN TO PERFORM AND A TTACH REQUIRED MA TERIALS (8) ry!DRIVEWAY APRON PERMIT: YOU MUST COMPLETE A - H BELOW IF YOU HAVE CHECKED THE DRIVEWAY APRON BOX. a. Attach a plot plan 11x17 or smaller. (If you are building or have a planning acrionJ turn in the same plan you wUl provide to Land Mgt) b. Choose One: [ ]Constructing New Approach [;X.Modi~ying Ex.istingApproach []Evaluation of Existing Approach c Width of driveway access at the property line ; cG (If no choice is made, we will provide you with the mInimum reql!irement) d. Apron Surface Request)OAsPhalt []Concr.ete. .1..]Gravel. (asphaltor concre}e.(;ni$1) i~ [F}gYJred_9Jl ea~f!.d rf??.d~) .. . e. How many tax lots will this access serve? 1-. How many accesses currently exist? ,z.. . f. Staking or flagging of the area is required. Describe how the access is marked:J LNtJ{'l~ ' o..d ~a g. Is this permit a requirement for: A Buiiding Permit? Y 0 or NO A Planning Action? Y1(f or N 0 (If yes -attach conditions of appr.oval) h. Describe the purpose of the access? (ex: home, RV pirk-ing, industrial) l:A~ . 7~ L01 ' . . . -.' , . i. Additional Comments (9) O'PROJECT DEVELOI'MENT/ROAD~CONSIRUCIION PERMIT: .Engineered plans and surety maybe required (SEE REVERSE) (10) 0 ROADSIDE LOGGING PERMIT: Staking or fiagging of the area is required Describe how the location is marked Mailing Address including Zip Logging Co. Describe Loggir::lg Activity: Phone (11) 0 UTILITY PERMIT: Submit 11X17 or smaller engineered plans. MUST mark locations with Pain! or flagging. Work Order # Approx mile post Description of Work (12) 0 OTHER WORK WITHIN THE RIGHT~OF~WA Y: Work in the right-at-way not covered above. Please describe the work in detail. Attach a site plan and supporting materials. Please slake or nag the area Application is hereby made for a facility permil for work to be done wilhin a Counly Road right-of-way. subject 10 alllerms. Conditions. agreemenls, slipulations, and provisions of the issued permit, pursuant 10 the rules and regulations regarding roads and rights-of:way. as set fOrlh in Lan(tCode 15. 05-225 and Lane ManuaI3.120-124 ano 15:505-550. and any other applicable regulation. law. or ordinance. The undersigned hereby declares, cerli~es and affirms under penally of law Ihal all informallon prOVided this form and al chmenls are. to Ihe best of my know1edge, true and complele. RETURN TO: Lane County Public Works . Permit Desk. 3040 N. Deita HiWp.~~~rt;'408 Tel. 541/682~6902 FAX 541/682.8500 H I g:rmRar'retlV(~8 . . . . ..... . anne. lane Counlycomp,e. ..,th SI~le a"~ Fed.r~ 10_ and regulohorlS rel;mng 10 dlScnmtna'"lrl, ,nCI"d.ng 'he ,\m~"can. 'Mlh Oisebi"".. ACl (ADA) 011990 R.v 07/01107 Date (6 (13) SIGNATURE (Property owner/authorized agenl) .1.'......,.:,.......... >, -"', "',;- j , ~ \ .~. :. \ \ i- . :.< . . . LANE COUNTY DEPARTMENT OF PUBLIC WORKS APPLICATION FOR FACILITY PERMIT For Office Use Only DATE: INCOMPLETE APPL/CA HONS WILL NOT BE ACCEPTED SEE PA GE 2 FOR INSTRUCTIONS AND FEES ALL PLANS MUST BE 11x17 OR SMALLER UNLESS AN ELECTRONIC COpy IS PROVIDED PERMIT # : JoI\I:b-.1 ~ \l:- PROP TY OWNER: Print Name (if different from Applicant) z,~l\ \AI.>( A~ Mailing Address: Street Address Ci~~~~ode Or q1 tQf ~i..;4-d 'V"".., .' ." ..,"" I Oayti .8 Phone YeQUired) (I) ~~e-\ 6. ~~...l' APPLICANT: nntName ~ \e:)q tG I'" ~ Mailing Address' Street Address ~~~ O~\ City~State;'Zip Code ~z.-il~\~ -o~14 Daytime hone ( equired) FAX ~~ t:;\o-4:oCA1 Evening one Cell Phone ~A11~&~'('1 w,.J , Got'\ E-mail Address (2) Road name nil;', \?hI 9 p\ FAX Evening Phone Cell Phone E-mail Address (3) MAP-TAXLOT~ ht.. z.d 4~ '1;'Ob Township ----RaPi'ge ~ Subsection Tax Lot Approximate Mile Post of RoaD. O~ (5) NearestTown ~....v.. fIB)? j:.~'?tAJ-l J.7\.:JO l...l _U3-IwClDO 1 J;ol V @ (4) Street address (if not addressed put NIA) ~.\e::; DFf, (6) Directions to site from nearest major cross road (7) CHECK ONE BOX BELOW THAT BEST DESCRIBES THE WORK YOU PLAN TO PERFORM AND ATTACH REQUIRED MA TERIALS (8) 0 DRIVEWAY APRON PERMIT: YOU MUST COMPLETE A-H BELOW IF YOU HAVE CHECKED THE DRIVEWAY APRON BOX. a. Attach a plot plan 11 x17 orsmaller. (If you are building or have a planning action. lurn in the same plan you will provide to Land Mgt) b. Choose One: [ jConstructing New Approach ~~odifying Existing Approach [jEvaluation of Existing Approach c. Width of driveway accesS at the property line ~ (If no choice is made, we will provide you with the minimum requiremenl) .d,. ApronSurface Request: . ~sPhalt [jConcrete [jGravel (asphalt or concrete finish is required on paved roads) e. How many tax lots will thisaceess serve? .\ .. -How many accesses .curreDtly exist? Z. f. Staking or fiagging of the area is required. Describe how the access is marked:J~t..1 ~ l~ . 'i)i:l" s:e:.r~ g. Is this permit a requirement tor: A Building Permit? Y 0 or NO A'Planning Action? Y ~or N 0 (Ify.e~'~ttac;h~?ndit;ons of appr~val) h. Describe the purpose of the access? (ex: home. RV parking. industrial) . . _vl..Jb,R CA ~ L Additional Comments r! CI '" U (,...,\ . (9) 0 PROJECT DEVELOPMENT/ROAD CONSTRUCTION PERMIT: Engineered plans and surety may be required (SEE REVERSE) (10) 0 ROADSIDE LOGGING PERMIT: Staking or fiagging of the area is required. Describe how the location Is marked Mailing Address including Zip phone Logging Co. Describe Logging Activity: (11) 0 UTILITY PERMIT: Submit 11X17 or smaller engineered plans. MUST mark locations with Paint or flagging.. Work Order # Approx mile post Description of Work (12) 0 OTHER WORK WITHIN THE RIGHT-OF-WAY: Work in the right-of-way no' covered above. Please describe the work in_detail. Attach a site plan and supporting materials. Please stake or flag the area A"Ii"lioo;, he"'y m'" t'" r,,;Ii'y p,ooit ,,,~" to bo '00' wi'h;" , COO"ty Roo' ;,ht-Of-my, "'i'ct to ,11 wm'. w"i'io",. ",,,moo". ";po"tioo'. ," proy;,;",,, or~, ;"", p,ooit. po"""' to ,he ru'" ,,' "'0"'''",''''''''"' ,,," '"' ,;,h"~f~Y.,, ,,' forth;" ",,, Cod' 15.200.225 '"' ",,, """'3.120-124'" '5.505.550. ,,' "y "h" 'PPIi"'" ",o"tioo."w." ,,"","co. Tho 00'''';'''' hereby declares, cel1lfles and affirms under penalty of law that allln/ormatiol1 pro de 0 this form a ttachmen~s are, to (he best of my knowledge, true and-complete. (13) SIGNA lURE (Property owner/authorized agent) RETURN TO: Lane County Public War 'ng Permit Desk, 3040 N. Delta Highway. Eugene, OR 97408 Tel. 5411682-c~~~"',oom.".'.'" ""..M ...,., ,,_ 'M .:~, ~:,~~~~,:~,~.~.~ .",.", '"' ,",,"u",;Q~~=~~d 54~ r3~~ ro, , . Planner: LM Date BI-z. /2"'10 .