HomeMy WebLinkAboutPermit Encroachment 1996-3-8
INSPECTION LINE SEE INSPECTIONS ON BACK SIDE
ENCROACHMENT PERMIT
NUMBER:
PERMIT NUMBER:
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1C~1V OF'SPRINGFIC)D' , . , PEr~JlIT APPLICATION,
225 FIFTH STREET _j~.':" ~
SPRINGFIELD, OREGON 97477 ':' ,.
ENGINEERING DIVISION ' '
OFFICE TELEPHONE f5031 726-3753 . ~ ~
APPLICATION DATE:
cJ J 2/ t?(//
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DATE ISSUED:
900 3/1 f-
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LOCATION OF WORK
APPLICANT :!}/-l/Ifhr All ~ ~<f?'"
SITE ADDRESS: .;2 J 0 7 ~-r-
~:cY//h~0eld STATE: 0;(
SUBDIVISION:
OWNER: V\fy /(;.,LL-(M. J tJc:./t?soA/
ADDRESS: CiTY:
CONTRACTOR: -;:; A /'> A;, - .,I/~U/.15'4 '1 ADDRESS:
CONTRACTOR REGISTRATION NO: t!t9.H bJ~f/7
, PROJECT SUPERVISOR: e/'JY& ~.I1S'/"
REQUESTED PERMITS:
PHONE
?~~~9?/j7
TAX MAP:
TAX LOT:
/7 -D5'- 2..G:, . 2,=5
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ZIP: t;'7 ~ 7 ;7
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PHONE:
STATE:
/7/9'/ ,{4ItVJ" Ill( IV CttfJL"'/N" ?J A:l
EXPIRATION DATE: / !:r-n !9~
ZIP:
PHONE: 6Rtf ?'?&Z-
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PHONE:
INSPECTIONS REQUIREO, APPLICATION FEE 10EPOSIT
ACCOUNT NO:
o ENCROACHMENT PERMIT NO: ..........~............i........ n
VALlO FOR SIXTY (601 OAYS FROM DATE OF ISSUANCE, , '
o CUT STREET 0 BORE 0 OTHER ~
o DUST CONTROL (TYPE OF CONTROL)
o CONSTRUCTION, STOR~GE, STAGING n
OO~~ n
o ASPHALT DEPOSIT.,..,.,..,......".,.". .'.,....'. ,..........", "....:, ..........,.,..............,....".,...."....,...,
o $20.00 /
0$
0$
0$
0$
IY.ef OF ~ECURITY DEPOSIT I
o BLANKET SURETY BOND 0 SURIITY BOND 0 CASH I CHECK
I(CURB CUT PERMIT NO: ............:.....'.. FT,' /:J." ~
INSPECTION' CURB I APPROACH AFTER FORMS ARE ERECTED BUT PRIOR TO POURING CONCRETE,
VALID FOR lBO DAYS FROM DATE OF ISSUANCE.
o SECOND DRiVEWAY iSEE SEPARATE APPLiCATION)
o SIDEWALK PERMIT NO: .................... FT. n
VALlO FOR 180 DAYS FROM DATE OF ISSUANCE,
o NEW 0 REMOVE I REPAIR, OPAVE PLANT STRIP
o SETBACK 0 CURBSIDE 0 LENGTH
llllSfEC.TII'I"" ~IOEWALK I DRIVEWAY FOR ALL CONCRETE PAVING WITHIN THE STREET RIGHT OF WAY. TO BE
MADE AFTER ALL eXCAVATING IS COMPLETE. AND FORM WORK AND SUB.BASE MATERIAL IS IN PLACE,
o SANITARY SEWER CONNECTION PERMIT: ................ n
VALID, FOR SIXTY (601 DAYS FROM DATE OF ISSUANCE
o TO STUB 0 MAIN LINE (EASEMENT-RM) 0 OTHER
o STORM SEWER CONNECTION PERMIT: .................... n
. VALID FOR SIXTY (60) DAYS FROM DATE OF ISSUANCE
o CATCH BASIN / BUBBLER 0 STUB 0 MAINLINE
PROOF 01= IN~URANCE. $500,000 MINIMUM
o A'TTACHED 0 REQUIRED AMOUNT.
0$
~00+$,15/FT. ~I 70
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o $10,OO+$.15/FT.
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o $5.00 I '
,
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TOTAL DUE: $
TOTAL DUE WITH PERMIT $
;f II, 7()
1?!L.7 ()
o $5,00/
DESCRIPTION OF PROJECT:
PERIOD OF USE OR TIME OF CONSTRUCTION:
~LANS (TWO SETS) ATTACHED
AREA: LENGTH: . .WIDTH:
TYPE OF WORK: CUT: i'
OTHER:
EXISTING SURFACE MATERIAL:
BACKFILL MATERIAL TO BE UTILIZED:
SURFACE REPLACErv1'ENT MATERIALS TO BE UTILIZED:
TYPE OF DUST CONTROL TO BE UTILIZED:
NAME OF OTHER UTILITIES IF THIS IS A JOINT PROJECT:
, "
WARNING DEVICES TO BE UTILIZED:
FROM DATE:
TO DATE:
DEPTH:
TIME:
TIME:
HEIGHT:
:"j
BORE:
, BACKFILL MATERIAL:
DESCRIPTION:
Advance signing and work zone protection to be in compliance with the Manual on Uniform Traffic Control Devices (MUTCD). '
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WORK SHALL COMPLY WITH CHAPTER X ARTICLE 6 OF THE CITY CODE. CONTRACTOR TO COMPLY WITH MUTCD .
REVISIONS 8/24/95 FORM # 116 ." .
.;.!\;.;
PLAN REVIEW COMMENTS / SPEr.IAL INSTRUCTIONS:
. ~
... RESTORATION WORK SHALL BE IN CL DRMANCE WITH EXISTING CITY CODES A"-_ IN dbMPLlANCE WITH CURRENT
.. STANDARD SPECIFICATIONS, EXCEPT AS NOTED BELOW. ,
001
002
003
004
005
006 .
007
008
009
010
011
012
013
014
015
016
017
018
Backfill with 'A" minus rock.
Compact every 18" loose depth.
Requires compaction with a steel roilier.
A.C. to match the greater of existing depth or 4".
All cuts sealed for final inspection.
Temporary patch may be used at the end of the day.
Signing and Zone protection to comply with MUTCD
Cut concrete only on score lines or cold joints,
Sidewalks and driveways min. 3,OOOpsi.
Curbing min 3,500psl/ No patchWork less than 3'.
Meet min. requlremEUlts on curb cuts. Spfd. code,
Restore planted areas, Sptd. code 206,3.05
Spec, to Bore / Jack / No A.C. cuts.
Mechanical compacting required,
No patchwork allowed.
Lateral cuts to have control density fill.
Cuts to be polymerized crack sealed for final inspection.
Minlnum 2" crushed rock '!." minus,
.' Comments:
;t r
'~ .
019
020
021
022
023
024
025
026
027
028
029
030
031
032
033
343
Minumum 4' clearance at any point. swing.away,
Concrete minimum 4" depth. 3.000psi.
Trench to be "T" cut.
Needs State I County parmlt'4 '
No above ground enclosings in sidewalk or handicap ramps.
Diamond cut A.C./Concrete value boxes to grade.
Fresh Oil signs / Graded.
Comply with Amaricans with Disabilities Act,
Concrete slabs. 72hrs. curing time. 4500psi,
Concrete slabs require joint saal material.
Driveway requires dowels every 18".
Submit traffic control plan prior to excavation,
Notify Traffic Division before excavatipn.
Core drill main line. insert tee. 2% min. grade,
Must comply with the provisions of ORS 757.541 to 757,571,
6" Circular hole/H20.Vac.
to
YOU ARE REQUIRED TO CALL .
THE LANE UTILITIES COORDINATING COUNCIL'S
"ONE CALL NUMBER" 1-800-332-2344
48 HOURS BEFORE DIGGING
, INSP~IONS:
[!(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.
o SANITARY SEWER, STORM SEWER, ENCROACHMENT PERMIT AND OTHER iNSPECTiONS CALL CITY MAINTENANCE AT
726-3761. '
SIGNATURE:
AMOUNT RECEIVED:
RECEIPT NO:
~ I( 10
r20&({L!
DATE PAID:
RECEIVED BY:
2>,- z-- r 0
- bt76 t:;,~k
y
By signature, I state and agree\ that I have carefully examined the completed application and do hereby certify that all information
herein is true and correct, and I further certify that any and all work performed shall be done in accordance With the Ordinances of the
City of Springfield, applicable City Standard specifications and Drawlngshand the laws of the State of Orellon pertaining to the work
described herein. I further certify that only contractors and employees w 0 are in compliance with ORS 701.055 will be used on this
project.
The City may inspect the work site described in this ,p.ermit at any time during a one year period following the receipt by the City of
notice of completion of the described work and speCify, at the City's sole descression. any additional restoration work required to
return the site to a standard acceptable to the City. Tlie permittee will be notified in writing of any work required and will have thirty
days (30) from the date of the notice to complete the work. Work not completed at the ena of the thirty days will be performed by the
City and the costs will be billed to the permittee.
I furthor agree to ensure that all required inspections are requested at the proper time. that project address is readable from the street,
and the approved set of plans will remain on the site at all times during construction.
Signature Q-I/) ~y 1Jl J)/{/~
jJ--PfA _ [ /
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VALIDATION:
o TRAFFIC REVIEWED BY:
o ENGINEERING REVIEWED BY:
o .MAINTENANCE:
o PERMIT ISSUED BY:
Date J-/ f / t?iR
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DATE:
DATE:
DATE:
DATE:
'.
FOR SIDEWALK AND CURB CUT PERMITS PLACE A COpy (COMPLETED) IN PERMIT DRAWER.
J
" ,INSPECTION : DATE:
INSPECTION: -.t DATE:
WORK IN PROGRESS DATE:
AT TIME OF COMPLETION: DATE:
ELEVENTH MONTH: DATE:
DEPOSIT RETURNED: DATE:
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