HomeMy WebLinkAboutPermit Encroachment 1998-6-22
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226: FIFTH STREET
SPRINGFIELD, OREGON 97477
ENGINEERING DIVISION
OFFICE-TELEPHONE (503) 726.3753.
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ENCROACHMENT PERMIT'
NUMBER: .
PERMIT NUMBER: . CJ7? tJ 7 4 '"1 '
INSPECTION LINE SEe INSPECTIONS ON BACK SIDE .
. , . .,
APPLICATION DATE:0'??"-,'j<6
"
DATE ISSUED:
\ LoeA TION OF WORK
APPLICANT ,~~~.-. ~ 'Gru~;,
SITE ADDRESS: -V~ ~ cD "'" </,~ '":r- ~"./vJf/"
CITY:.'/ .-..d/_Cl STATE: 0..,
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SUBDIVISION:
OWNER: Li,7!/:: .x ~-".4
ADDRESS: ? ~ 9'~ ,.k'r; d. .
CONTRACTOR: ~ x/hW/U'.rrn ~
/ .:
CONTRACTOR REGISTRATION NO:
PROJECT SUPERVISOR:
,PHONE 9</:<..3 <;17 7
uJ, ~f
ZIP:" :1 <V '7 -r
TAX MAP:
TAX LOT:
17Q:;3.;;1q~
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,PHONE:
CITY:~'p -21~/.-(J .sTATE: O.A
. J
ADDRESS:3575/ rz A>.J. J .GyJ~ a,.../7
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. EXPIRATION,DATE:
97/;;;-.2:, 4'7 7
. ZIP: 9' 7S/.;} </
PHONE: ~i/.2-77'/7
, -.
PHONE:
REQUESTED PERMITS:
INSPECTIONS REQUIREO, APPLICATION FE! I DEPOSIT
ACCOUNT NO:
o ENCROACHMENT PERMIT NO: ,.."'"....""...".....!.,,. n
VALID FOR SIXTY (801 DAYS !'ROM DATI! OF ISSUANCE
o CUT STREET. 0 BORE Q OTHER n
o DUST CONTROL (TYPE OF CONTROU
,
0$20.001
',0 $
o CONSTRUCTION, ~T9RAGE. STAGING
o OTHER
n
n
O.
o .'
a.
a ASPHALT 0 EPOSIT ........,.. ..........".... ...........,.........,..................... ....................... ......... .......
TYPE OFSECURITY DEPOS/l
o BLANKET: SURETY BOND 0 SURIITY BOND 0 CASH 1 CHECK
o CURB CUT PERMIT NO: ................~." FT.,. , . 0
INSPflrrlON' CURB I APPROACH AFTER FORMS ARE ERECTED BUT hilOR TO POURING CONCRETE,
..,. VAllO FOR 180 D...V8 FROM. DATI! OF ISSUANCE.
Q seCOND DRIVEWAY (SeE SEPARATE APPUCAnON)
o SIDEWALK PERMIT NO:.................... FT.
VALlO FOR 180 DA V8 FROM DATI! OF ISSUANCE.
Q NEW 0 REMOVE I REPAIR QPAVE PLANT STRIP
Q'SETBACK 0 CURBSIDE Q LENGTH
IN!:PF~TlnN. !:IDEWAlK I DRIVEWAY FOR All CONCRm PAVING WITHIN THE STREET RIGHT OF WAY, TO BE
MADE AFTER All EXCAVATINQ IS COMPlETE . AND FORM WORK AND 8UlJ.BASE MATERIAllS IN PUCE.
II SANITARY SEWER CONN'ECTION'PERMIT: ................ n
VALlO FOR SIXTY 1801 DAYS FROM DATI! OF ISSUANCE
. il TO STUB Q MAIN LINE /EASEMENT-R/WI 0 OTHER
o STORM SEWER CONNE.CTION PERMIT: ........;....;.....,n
VAllO FOR SIXTY (801 DAYS FROM DATI! 01' ISSUANCe , .
Q CATCH BASIN / BUBBLER a STUBQMAINLlNE
PROOF OF INSlJRANCI;. $600,000 MINIMUM
, 0 ATTACHeD 0 REQUIRED AMOUNT
O.
o .10.00+$.16/FT.'
~/
fl
'0 $10.00,+$.16JFT..
. .I......
tf~,., '. t2J %J
..'
0, $5.001
.n th.' C50 ,
TOTAL DUE:. . G-v
TOTAL DUE WITH PERMIT. .
DESCRIPTION OF PROJECT:
PERIOD OF USE OR TIME OF CONSTRUCTION:
'0 PLANS (TWO SETS)ATTf.CHED
AREA: LENGTH:
TYPE OF WORK: CUT:
OTHER:
EXISTING SURFACE MATERIAL:
BACKFILL MATERIAL TO BE UTILIZED:
SURFACE REPLACEM'ENT MATERIALS TO BE UTILIZED:
TYPE OF OUST CONTROL TO BE UTI~IZED:
NAME OF OTHER UTILITIES IF THIS IS A JOINT PROJECT:
WARNING DeVICES TO BE UTILIZED: ,
Advance.llgnlng and work zone .protectlon to be In compliance with the Manual on Uniform TraUlc Control Devices (MUTeO),
WIDTH:
FROM [)A TE:
TO DATE:
)
DEPTH:
, TIME:
. TIME:
HEIGHT: '
BORE:
. BACKFILL MATERIAL:
DESCRIPTION:
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~.-...." """'''''.'''::}<~'':'.'''.--.'.'-
; . ..,~,
WORK SHALL COMPLY WI'''':' CHAPTER X ARTICLE 6 OF THE CITY CODE. CONTRACTOR TO COMPLY WITH MUTCD ,
REVISIONS8/24195 .. FORM' 118 I
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