HomeMy WebLinkAboutPermit Encroachment 1996-4-19
CITY OF, SPRING' ~LD' , " pr'1MIT APPLICATION
225 FIFTH STREET
SPRINGFIELD, OREGON 97477
ENGINEERING DIVISION
OFFICE TELEPHONE (503) 7'26-3753
ENCROACHMENT PERMIT
NUMBER:
PERMIT NUMBER: 9S-C:::>9/~/
INSPECTION LINE SEE INSPECTIONS ON BACK SIDE
APPLICATION DATE:
~'i9-%
DATE ISSUED:
0/"'/7'- 5'6
LOCATION OF WORK
APPLICANT fJ~t!!rT"75~r..4 ~'
SITE ADDRESS: 5" /t./ c:;:;> 5~
CITY: ~n-'--h STATE: ~A.
SUBDIVISION:
OWNER: .~~~...y k~c/~
ADDRESS: ra ~Y" '<>~5- CITY: C=--&-4 eo~~' STATE:
'CONTRACTOR: L:2: ~fiPZ?/ ADDRESS: -:?~~:p~ ~.c:=--
CONTRACTOR REGISTRATION NO: ~33 y , EXPIRATlo'~ ~ATE: /7~--96
PROJECT SUPERVISOR: PHONE: .
PHONE .~ 5'... -:::>/~.~
TAX MAP: /''''7 '<b' ~ t:.r
TAX LOT:. ~S:S-~'3"
ZIP:
7'/C/ ./?
PHONE: ~ '? S'" 3/3-.~ .
ZIP: q::; Y-&S:2....
PHONE: -~~/z.
REQUESTED PERMITS:
INSPECTIONS REQUIRED: APPLICATION FEE I DEPOSIT
ACCOUNT NO:
o ENCROACHMENT PERMIT NO: ............................... n
VALID FOR SIXTY (601 DAYS FROM DATE OF ISSU,ANCE
o CUT STREET 0 BORE 0 OTHER
ODUST CONTROL (TYPE OF CONTROL)
o CONSTRUCTION, STORAGE, STAGING
o OTHER
o ASPHALT DEPOSIT..,.....,..,...,......"",,,.........,,,,,..
n
o $20.00 /
0$
n
n
0$
0$
0$
.............................................................
TYPE OF SECURITY QEPOSIT
o BLANKET SURETY BOND 0 SURIITY BOND 0 CASH / CHECK
~ ' ;;tit.JE""
CURB CUT PERMIT NO: ...~"!':r.".... FT. /b 0 .
INSPECTION' CURB I APPROACH AFTER FORMS ARE ERECTED BUT PRIOR TO POURING CONCRETE.
'.,,,, VALID,FOR lBO OAYS FROM DATE OF ISSUANCE.
o SECOND DRIVEWAY (SEE SEPARATE APPLICATION)
o SIDEWALK PERMIT NO: .................... FT. /b
0$
o $10.00 + $.15/FT.
/:2~~~
. .
[JJ
VALID FOR lBO DAYS FROM DATE OF ISSUANCE,
o NEW 0 REMOVE' / REPAIR 0 PAVE PLANT STRIP
o SETBACK. 0 CURBSIDE 0 LENGTH
INSPFC~TION' SIDEWALK 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
o
o $10.00+$.15/FT. /:<> - L/O
VALID FOR SIXTY (601 DAYS FRO~ DATE Of ISSUANCE
o TO STUB 0 MAIN LINE (EASEMENT:R/W) 0 OTHER
o STORM SEWER CONNECTION PE~MIT: .................... n
VALID FOR SIXTY (60) DAYS FROM DATE OF ISSUANCE
o CATCH BASIN / BUBBLER 0 STUB 0 MAINLINE
PROOF OF INSURANCE' $500,000 MINIMUM
o ATTACHED 0 REQUIRED AMOUNT
o $ 5.00 / '
. 0 $5.00/
'-
TOTAL DUE($
TOTAL DUE WITH PERMiT $
~ y c;;;> c;:,
DESCRIPTION OF PROJECT:
PERIOD OF USE OR TIME OF CONSTRUCTION:
o PLANS (TWO SETS) ATTACHED
AREA: LENGTH: ,WIDTH:
TYPE OF WORK: CUT:
OTHER:
EXISTING SURFACE MATERIAL:
BACKFILL MATERIAL TO BE UTILIZED:
SURFACE REPLACEM'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 I?A TE:
TO DATE:
DEPTH:
, TIME:
TIME:
HEIGHT:
BORE:
BACKFILL MATERIAL:
.... .
DESCRIPTION:
Advance signing and work zone protection to be in compliance with the Manual on Uniform Traffic Control Devices (MUTCD),
4
WORK SHALL COMPLY WITH CHAPTER X ARTICLE 5 OF THE CITY CODE. CONTRACTOR TO COMPLY WITH MUTCD'.
REVISIONS 8/24/95 -FORM # 116
PLAN REVIEW COMMENTS I SPEr'~L INSTRUCTIONS:
~
,
RESTORATION WORK SHALL BE IN COfll......JRMANCE WITH EXISTING CITY CODES ANL. .ri'~MPLlANCE WITH CURRENT
STANDARD SPECIFICATIONS, EXCEPT AS NOTED BELOW. .
001
002
003
004
005
006
07
008
009
010
~, 011
012
013
014
015
016
017
018
COmments: '
Backfill wi~h Yo" minus rock.
Compact every 18" loose depth.
Requires compaction with a steel roilier.
A.C. to match,th~,greater of existing depth or 4".
All cuts sealed for final"i1;spection.
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 3,500psi / No patchwork less than 3'.
Meet min. requirements on curb cuts, Spfd. code.
Restore planted areas, Spfd. code 206.3:05
Spec. to Bqre.l Jack I No A.C. cuts.
Mechanical'compacting required.
t\lopatchwor,k allowed.
Lateral cuts to have control density fill.
Cuts to be polymerized crack sealed for final inspection.
Mininum 2" crushed fl?ck ';." minus.
019
- 020
021
E 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,OOOpsi.
Trench to be "T" cut,
Needs State / County permit. ,
No above ground enclosings in sidewalk ot handicap ramps,
Diamond cut A.C.lConcrete value boxes to grade,
Fresh Oil signs / Graded,
Comply with Americans with Disabilities Act,
Concrete slabs, 72hrs, curing time, 4500psi.
Concrete slabs require joint seal material.
Driveway requires dowels every 1.8". .
Submit traffic control plan prior to excavation,-,
Notify Traffic Division before excavatii>n,
Core drill main line, ins'ert tee, 2% min, grade,
Must c'omply with the provisions of ORS .757,541 to 757.571.
6" Circular hole/H20,Vac.
YOU ARE REQUIRED TO CALL
THE LANE UTILITIES COORDINATING COUNCIL'S
"ONE CALL NUMBER" 1-800-332-2344
48 HOURS BEFORE DIGGING
SIGNATURE:
. ...
:;
AMOUNT RECEIVED: '2 y. ~
RECEIPT No:2/~ /
DATE PAID:
RECEIVED BY:
INSPECTIONS:
llr'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
726-37-61 .
?/'/9 ~
~~-- ~.
'//
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 Oregon pertaining to the work
described herein. I further certify that only contractors and employees w 0 are in compliance with ORS 7m .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. '
s;gn"u"~ D"e 7O-/Y- 5'G
VALIDATION:
0 TRAFFIC REVIEWED BY: DATE:
0 ENGINEERING REVIEWED BY: DATE:
0 MAINTENANCE: DATE:
0 PERMIT ISSUED BY: DATE:
"
FOR SIDEWALK AND CURB CUT PERMITS PLACE A COpy (COMPLETED) IN PERMIT DRA WER.
INSPECTION: . DATE:
INSPECTION:
WORK IN PROGRESS
AT TIME OF COMPLETION:
ELEVENTH MONTH:
DEPOSIT RETURNED:
DATE:
DATE:
DATE:
DATE:
I'
DATE: j