HomeMy WebLinkAboutPermit Sidewalk 1999-10-25
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DRIVEWAY/SIDEWALK: .' " PERMIT APPLICATION
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225 FIFTH. STREET
SPRINGFIELD, OREGON 97477
ENGINEERING DIVISION
OFFICE TELEPHONE (503) 726-3753
APPLICATION DATE: /0- crS,- 0, ~
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PERMIT NUMBER:
DATE ISSUED:
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U4?D'~ 7A?
~ 1""'57 '/"""
SITE INFORMATION:
LOCATION ~ORK: ;;t.?-d-~ 12~ S.1~
APPLICANT 1 ).el/\ \1'\1 ~ jfa~rlf)i.A j .
ADDRESS:' .'J- 'J--?--:L ~ b'iJ---{J.,.i
CITY YJ'I~"'! c! STATE O,L ,
SUBDIVISION: 'I cH . t2t:J DoHA-v le-W
OWNER:~AAUI( d 6i/'~ JI&/l~
ADDRESS ~:t ~i CITY ~r/J'
. PHONE 7V~ - '105'2 j/J' -:JU--/~fjJ-r0
TAX MAP: 11'- 03 --;}5'
ZIP: .
~-JC/71
TAX LOT: Ol/() D
PHONE:
STATE:/P ~
Zlp:CJjl.! /7
REQUESTED PERMITS:
o ~:I~~:~Y~~~I~:~~L~~~~:~~~~"~~~;.""""'!'715"""'"'@$O"~'~"SF:""': 6~.~
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o SIDEWALK REPAIR: ..................'...................................,...,..,.........,.............$ 10.00.
. 0 ADDITIONAL DRIVEWAY:
............ ............. ................. .......................,..$ 30.00
o PROOF OF INSURANCE: $500,000 MINIMUM IF WORK IS DONE BY PROPERTYOWNER
TOTAL DUE WITH PERMIT $ (// t , ~ 0
CONTRACTOR INFORMATION:
CONTRACTOR: '\) G:ll-.J ~ tC'-..
ADDRESS:
CONTRACTOR REGISTRATION NO:
PROJECT SUPERVISOR:
H-t1\-f7. I C'll...!L \ '"' C> U-J ~~q;:
PHONE:
EXPIRATION DATE:
PHONE:
INSPECTIONS:
AN INSPECTION REQUEST SHOULD BE MADE PRIOR TO POURING CONCRETE, AFTER THE PROPOSED WORK HAS BEEN FORMED
AND MADE READY TO POUR. . .
,
CURB CUT AND SIDEWALK INSPECTIONS CALL 726-37~9 (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 REQUIRED TO CALL
THE lANE UTiliTIES .COORDINATING COUNCil'S
"ONE CALL NUMBER" 1-800-332-2344
48 HOURS BEFORE DIGGING
SIGNATURE:
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(a I . \ ~-' lh I f a 0-..
AMOUNT RECEIVED: l DATE PAID: ~ I.) '7..-~ t.. I
RECEIPT NO: O-~ Gf D . RECEIVED BY: \ C~/\. I.
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 correctl 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 StandarC! specifications and Drawings, and the laws of the State of OreQon p'ertaining to the work
desc~ioed ~erein. I furth~H certify that only contractors and employees who are in compliance with ORS 701.055 will be used
on this proJect.
The City mpy inspect the vyork site described ifl this perm}t C}t any time duril")g a one year period follow}ng the receipt by. the City of notic.:
of completion of the deSCribed work and speCify, at the City s sole descresslon, any additional restoration work re~U1rea to return the Sitf:
to a standard acceptable to the City, The permittee will be notified in writing of any work required and will have thirty days (30) from the.
date of the notice to cOll!plete the work. Work not completed at the end 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, ana the apP?jt of plans will r:main on the ,site at all times during construction.
Signat~~ ~h / 4h ' Date ,/b-;rs-qc,