HomeMy WebLinkAboutPermit Building 1997-3-20 (2)
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" CITY OF' SPRINGf ~LD _",. . pr "!MIT APPLICATION
'- _' I .
225 FIFTH STREET
SPRINGFIELD. OREGON 97477
ENGINEERING DIVISION
OFFICE TELEPHONE 15031 726.3753
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ENCROACHMENT PERMIT
NUMBER:
PERMIT NUMBER: <?~ /~ ~
INSPECTION LINE SEE INSPECTIONS ON BACK SIDE
APPLICATION DATE:
';? -"20, '7 ?
DATE ISSUED:
" -
LOCATION OF WORK
APPLICANT /?~z:./A'" ""'5#//",?_Cr
SITE ADDRESS: //// . ~A'1~ ~/y~,
CITY: STATE: ZIP:
?,-;?<:::5 --;:5 ~
PHONE~' e::>~ :?
TAX MAP: /:?.y;:)~<?- s.r7'
TAX LOT: ~-5'51c;3
SUBDIVISION:
OWNER: #C/fY ....,.6-'/ .A"~7 PHONE:
ADDRESS: /~~D 7)'7...y'~-1?: CITY: ~~ STATE: ~A_
CONTRACTOR: .#~/1"'Jf'X/~ ADDRESS: ~ S~/k;9, ?p~.i7:>
L '/. , /
CONTRACTOR REGISTRATION NO: ~!!:~ ./ EXPIRATION DATE: "7""':< '">~"'3?
PROJECT SUPERVISOR:
REQUESTED PERMITS:
ZIP: 9-:;><;./.:::>":2..
PHONE: ?V>~
PHONE:
INSPECTIONS REQUIRED: APPUCATION FEE I DEPOSIT
ACCOUNT NO:
o ENCROACHMENT PERMIT NO: ............................... n
VALID FOR SIXTY (60) DAYS FROM DATE OF ISSUANCE
o CUT STREET 0 BORE 0 OTHER
o OUST CONTROL ITYPE OF CONTROLI
n
o CONSTRUCTION, STORAGE, STAGING
o OTHER
o ASPHALT DEPOSIT......
n
n
TVPF OF ~Fr.IIR1TV nFPO~Il:
o BLANKET SURETY BONO 0 SURIITY BOND
o CASH I CHECK
o CURB CUT PERMIT NO: .................... FT. n
IN"PFCTlnN' CUR8 I APPROACH AFTER FORMS ARE ERECTED 8UT PRIOR TO POURING CONCRETE.
VALID FOR 180 DAYS FROM DATE OF ISSUANCE.
o SECON'D DRIVEWAY (SEE SEPARA TE APPLlCA TlON)
o SIDEWALK PERMIT NO: .................... FT. 0
VALID FOR 180 DAYS FROM DATE OF ISSUANCE.
o NEW 0 REMOVE I REPAIR 0 PAVE PLANT STRIP
o SETBACK 0 CURBSIDE 0 LENGTH
J'lIc:pr:jT\!'W.:...SIOEWALK I DRIVEWAY FOR ALL CONCRETE PAVING WITHIN THE STREET RIGHT OF WAY, TO 8E
MADE AFTER ALL EXCAVATING IS COMPLETE. AND FORM WORK AND SU8.BASE MATERIAL IS IN PLACE.
)fl SANITARY SEWER CONNECTION PERMIT: ................ n
VALID FOR SIXTY (601 DAYS FROM DATE OF ISSUANCE
o TO STUB 0 MAIN LINE IEASEMENT.RIW) 0 OTHER
J1' STORM SEWER CONNECTION PERMIT: .................... n
VALID FOR SIXTY 1601 DAYS FROM DATE OF ISSUANCE
o CATCH BASIN I BUBBLER 0 STUB 0 MAINLINE
PROOF OF INSlJRANCF' $500.000 MINIMUM
o ATTACHED 0 REOUIREO AMOUNT
0 $20.00 /
0 $
0 $
0 $
0 $
0 $
0 $10.00+$.15/FT.
o $10.00+$.15/FT.
,
o $5.00/.
~~
o $5.00/
~~.
/./ .
.'-'"
TOTAL DUE: $
TOTAL DUE WITH PERMIT $
/C7. ~
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 REPLACEIVIENT 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:
BORE:
BACKFILL MATERIAL:
TIME:
TIME:
HEIGHT:
DESCRIPTION:
Advance signing and work zone protection to be in compliance with the Manual on Uniform Traffic Control Devices (MUTCD),
WORK SHALL COMPLY WITH CHAPTER X ARTICLE 5 OF THE CITY CODE. CONTRACTOR TO COMPLY WITH MUTCD.
REVISIONS 8/24/95 FORM , 116
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PLAN REVIEW COMMENTS I SPEWL INSTRUCTIONS:
RESTORATION WORK SHALL BE IN CO~MANCE WITH EXISTING CITY CODES AN. ~MPLlANCE WITH CURRENT
STANDARD SPECIFICATIONS. EXCEPT A;, NOTED BELOW.
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Comments:
001
002
003
004
005
006
007
008
009
010
011
012
013
014
015
016
017
018
Backfill with ,,- minus rock.
Compact every 18" loose depth.
Requires compaction with 8 steel rolller.
A.C. to match the greater of existing depth or 4".
All cuts sealed! for finat inspection.
Temporary patch may be used at the end of the day.
Signing and Zone protection to comply with MUTeD
Cut concrete only on score lines or cold joints.
Sidewalks end driveways min. 3.000psi.
Curbing min 3.500psi I No patchwork less than 3'.
Meet min. reqJ'jrements on curb cuts. Spfd. code.
Restore planted areas, Spfd. code 206.3.05
Spec. to Bore !Jack I No A.C. cuts"
Mechanical.c,?~pacting required.
No patchwork allowed.
Lateral cuts to have control density filt.
Cuts to be polymerized crack. sealed for final inspection.
Mininum 2" crushed rock. %" minus.
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019
020
021
022
023
024
025
026
027
028
029
030
031
032
0~3
343
Minumum 4' clearance at any point, swing.away.
Concrete minimum 4" depth, 3,OOOpsi.
Trench to be "T" cut.
Needs State I County permit.
No above ground enclosings in sidewalk or handicap ramps.
Diamond cut A.C./Concrete value boxes 10 grade.
Fresh Oil signs I Graded.
Comply with Americans with Disabilities Act.
Concrete slabs. 72hrs. curing time. 4500psi.
Concrete slabs require joint seal material.
Driveway requires dowels every 18".
Submit traffic control plan p~ior to excavlltion.
Notify Traffic Division before excavat;~n.
Core drill main:line, insert tee, 2% mln. grade.
Must comply with the provisions of ORS 757.541 to 757.571.
6" Circular hole/H20-Vac.
YOU ARE REOUIRED TO CAll
THE LANE UTILITIES COORDINATING COUNCIL'S
"ONE CALL NUMBER" 1-800-332-2344
48 HOURS BEFORE DIGGING
INSPECTIONS:
o CURB CUT AND SIDEWALK INSPECTIONS CAll 726-3769 (RECORDERI 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. / 1 A
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SIGNATURE:
AMOUNT RECEIVED:
RECEIPT NO:
/ ~ . c.rr;.
? ~t:? '5""/
DATE PAID:
RECEIVED BY:
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By signature, I state and agreej that I have carefully examined the completed application and do hereby certify that all information
herein is true and correct, and 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 Draw,ngshand the laws of the State of Ore-.9on 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. The permittee will be notified in writing of any work required and will have thirty
days (301 from the date of the notice to complete the work. Work not campleled at the eno 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
Date
VALIDATION:
o TRAFFIC REVIEWED BY:
o ENGINEERING REVIEWED BY:
o MAINTENANCE:
o PERMIT ISSUED BY:
DATE:
DATE:
DATE:
DATE:
FOR SIDEWALK AND CURB CUT PERMITS PLACE A COPY /COMPLETEDIIN PERMIT DRA WER.
INSPECTION:
INSPECTION:
WORK IN PROGRESS
AT TIME OF COMPLETION:
ELEVENTH MONTH:
DEPOSIT RETURNED:
DATE:
DATE:
DATE:
DATE:
DATE:
DATE: