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Home My WebLink AboutApplication APPLICANT 8/18/2010 . . 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 ANa FEES ALL PLANS MUST BE 11x17 OR SMALLER UNLESS AN ELECTRONIC copyrs PROVIDED PERMIT;:: II) ~~ ,. ~u(, APPLICANT: Print Nam;" It;G) ~\(, A'v'r. Mailing P..ddress: Street Address al6~G .~.," Q110! City, State, Zip Code ., cd-HAt- c:{p\; 01,,1'1- ~hone (Required) FAX ~t:~IO- 40Ql Cell Phone, ~.J"~ @ "1c7,J <Wt E-mail Address ~ ~,.Jt:- PROPERTY OWNER: Print Name (if different from Applicant) l.P') \ ....11.1 A-.Ar Mailing Address: Street ,I'l,ddress eII~~ ,~ "\7tD4 City, State, Zip Code - -- . :a(-~'Z!Z-' Daytime Phone (Required) FAX Evening Phone Cell Phone E-mail Address (2) Road name ..-11t,~ I~If'l (3) MAP - TAX LOT ~ ~?nge ~ -A~tion j ?~~l (4) Street address (if not addressed put N/A) ~ \ ~< Approximate Mile Post of Road f). t>., (5) Nearest ~own ~.,J'?I~ (6) Directions to site from nearest ~ajor cross road ~,.J~J "....."" 0' --+- 1"11~ l~ I pi I . . (7) CHECK ONE BOX BELOW THi>. T BEST DESCRI/?ES THE WORK YOU PLAN TO PERFORM AND A TTACH REQUIRED MA TEFIIALS (8) ry! DRIVEWAY APRON PERMIT: YOU MUST COMPLETE A- H BELOW IF YOU HAVE CHECKED THE DRIVEWAY APRON BOX. a. Attach a plot plan 11 x17 or smaller. (If you are building or have a planning action, turn ;n the same plan you wifl provide to Land Mgt) b. Choose One: [ ]Constructing New Approach [~MOdjfYing Existing Approach []Evaluation of Existing Approach c. Width of driveway access at the property line ~~ (/fno choice is made, we wil/ provide you with the minimum requirement) d. Apron Surface Request )(:]ASphalt []Concr-ete []GralJel (asphalt or concrete fini~h i~ r~gt!J!ed _on eaved roads) e. How many tax tots w\1I thiS access serve? \ How many accesses currently eXIst? k f. Staking or flagging of the area is required. Describe how the access is marked:J tJ)&{'.I~ . O..J ~a g. Is this permit a requirement for: A Buiiding Permit? Y 0 or NO A Planning Action? YlC\' or N'O ('t-yes-attach conditions of approval) h. Describe the purpose of the access? (ex: home, RV pa"rking, industrial) ~,.. . <,~ 1..1)1' . . . ". i. Additional Comments (9) 0 PROJECT.DEVELOPMENTIROAD.CONSIRUCTION PERMIT: .Engineered plans and. surety may be required (SEE REVERSE) (10) 0 ROADSIDE LOGGING PERM'IT: Staking or flagging of the area is required. Describe how the location is marked Mailing Address including Zip Logging Co. Phone Describe LoggiF-lQ Activity: (11) 0 UTI LIlY 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 not covered above. Please describe the work in detail. Attach a site plan and supporting materials. Please slake or flag the area App~calion is hereby made I.or a facility pen:ni! for y.,urk 10 be done wi.lhin a County Road right-of-way, subject 10 alllerms, conditions, agreements, stipulalioos, and provisions of the issued permit, pursuanllo lhe rules and regu1alH)OS regarding roads and nghls-of:way. as set IOllh In Lani;..Code 15. 05-225 and Lane Manual 3.120-124 and 15.505-550. and any other applicable regulallon. law. or ordin3rt(;e. The undersigned hereby declares. cerlifies and affirms under penally of law that all informalion provided IhlS form and al ehmenls are, to Ihe best of my knowledge. lrue and complete. Permit Desk, 3040 N. FAX 5411682.8500 D~Il1iltfi!JRe,celijeti: 0 Pla/iAer~ It;Mred 541/ 82-3995----. (13) SIGNATURE (Property owner/authorized agent) RETURN TO: Lane County Pubiic Works Tel. 5411682.6902 Lane Ccu",y ""mpio.. "';1" S131~ ~f\d F~d.r"'law:o 31'\0 regulolions relating l<> discrimination. including 'no AmM;cans ,.,;th OISBbirtl;e. ACI (AI)A,) of 1990 Rov07/Ol107 . . LANE COUNTY DEPARTMENT OF PUBLIC WORKS APPLICATION FOR FACILITY PERMIT For Office Use Only DATE' INCOMPLETE APPLlCA TIONS WILL NOT BE ACCEPTED SEE PAGE 2 FOR INSTRUCTIONS AND FEES ALL PLANS MUST BE 11X17 OR SMALLER UNLESS AN ELECTRONIC COpy IS PROVIDED PERMIT# , ~ \l:- PROP TY OWNER: Print Name (if different from Applicant) z,.t;L\ IA~ Mailing Address: Street Address Ci~~~~ode Or q1 ~ ~i ..;~. ~;z.., Dayti e phone equired) (I) ~~e-l (", ~~...l' APPLICAN1: nntName ~ \e:;q r& \(, ~ ~ailing Address: Street Address ~~~ O~\ City;. State, Zip Code ~~~~\4 --O~~ Daytime hone ( squired) FAX ~' t:;\o-4:0'1V Evening one Cell phone ~~&~(.(OW7....1 . COn E-mail Address (2) Road name t"\1~1f:,t,1 VP\ N FAX Evening Phone Cell Phone (3) MAP-TAXLOT'~ fir.. z.d 4~ ~;'Ob Township ~ ~ Subsection Tax Lot Approximate Mile Post of RoaIJ.O.; (S) NearestTown 4VfI"j("fK;V') t~'?UJ-l P7t..V'O l,..l #I,,(3.JWO!1O I F.,L..lC- @ E-mail Address (4) Street address (if not addressed put N/A) ~ \t; nst:- (6) Directions to site from nearest major cross road (7) CHECK ONE BOX BELOW THAT BEST DESCRIBES THE WORK YOU PLAN TO PERFORM AND A ITACH 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 or smaller. (If you are building or have a planning action, turn in the same plan you will provide to Land Mgt) b. Choose One: [ jConstructlng New Approach ~~odlfylng Existing Approach [jEvaluatlon of Existing Approach c. Width of driveway access at the property line ~ (If no choice is made, we will provide you with the minimum requirement) d, Apron Surface Request:~SPhalt [jConerete []Gravel (asphalt or concrefe finish is required on paved roads) e. How many tax iots will this .access serve? l.. . - How many accesses currently exist? Z. f. Staking or flagging of the area is required. Describe how the access is marked:~~60U.Jj". .Oi..r.-J:~~ g. Is this permit a requirement for. A Building Permit? Y 0 or NO A Planning Action? Y ~or N [j (Ifyes-~tta,h '!(}nditiOn; of approval) h. Describe the purpose of the access? (exc home. RV parking. industrial) . -,JL.Jb.f1l CA ~ i. Additional Comments CI e. u l,.,j .. (9) 0 PROJECT DEVELOPMENTIROAD CONSTRUCTION PERMIT: Engineered plans and surety may be required (SEE REVERSE) (10) 0 ROADSIDE LOGGING PERMIT: Staking or flagging of the area is required. Describe how the location Is marked Mailing Address including Zip Logging Co. Describe Logging Activity: Phone (11) 0 UTtLlTY PERMIT: Submit 11X17 or smaller engineered plans. MUST mark locanons with Paint or flagging.. Work Onder # Approx mile post Description of Work (2) 0 OTHER WORK WITHIN THE RIGHT.OF-WAY: Work in the right-of-way not covered above. Please describe the work in_detail. Attach a site plan and supporting materials. Please stake or flag the area AppU'''''' I, ",,,Oy m".loe' r,du~ p,.,,;1 loe ~~ to 0, do", "'~I" , eOU"~ Ro" ""'I~I-"'y. "Oi.d to ,,' 10m'. ",o;tioo>. 'g"""""' "'p,Iotioo>. "" pro.""" of~. ",co, p.mit. p'""''' to "" """ ",d "g,IotiO"' """",g "," 00' 'gh"~f~y. " ,,. forth" ,,"' Cod' \5.205-225 ,'" ,,"' ",'",' 3.120.124 00' "505-550. 00' ooy o~" ,,,",,,,. ~g"Io'''''. ,... or 0""","'. Th. '''''''g"'''' h.~Oy """". ,,01"" ,,' ,ffi,,'" CO," ,,,,,',~" ,..." ,It I,fo,,"""" pm d. ~" 'o<m' ",ohm"" ,~. " 1M ,,,' of my """edg,, IN' ",,,,mp''''. . Oat ng Permit Desk, 3040 N. g.li\Yl-i~~il!~' FAX 541/682-8500 Planlllel~nt.M>aired 54 /68 (0 (13) SIGNATURE (Property owner/authorized agent) RETURN TO: Lane County Public War Tel. 541/682-6902 Lana Co~nIy compllas willi Sial.. and Fed"",I18_ aod ~ulaliona ",,,"ling 10 dlscrimirtalion. in<Judi..q ,~~ "mariam. willi Di$abllillas Ad (AQ.I.) of 1990 R""rrrlO,107