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City of Salem REVOCABLE PUBLIC RIGHT-OF-WAY <br />Peblic WOrks Department ~• ~ ENCROACHMENT PERMIT APPUCATION <br />T~affic Engineering Division ~~f sa~m <br />555 Liberty Street SE, Room 325 ~ GQQ•6256 P~D No. <br />Salem, Oregon 97301-3503 ~ `,pV <br />elephone: (503) 588-6211 ~~ Filing Fee 8324.00 <br />:(503) 588-6292 (p~t e~p~Catio~i Cente~) Automation Fee S 2.50 <br />Processing Fee S 7.50 <br />Total $334.00 <br />Application No. <br />APPLICATION FOR PUBLIC RIGHT-OF-WAY ENCROACHMENT REVOCABLE PERMIT AGREEMENT <br />REFERENCE SRC 76.160, 76.165 <br />1. APPUCANT INFORMATION: <br />Name: ~a2~d.~ ~-*s ~.~rr ~ ~-~L.F~ ~2~ u.~A~ -rn A- ~c,.~c ~~Trz.cT <br />Address: I fb IG-u 5f 1~E Sa.Eu ~ 77 *~ - 3670 ~~ 31~d,D (~~ ~ ~ 1~.E ~r~,t. <br />Telephone (business): M~,.54~-~ Se~~no 5te Z~Z~ (home) 9T'.~o3"`~I65 <br />2. ENCROACHMENT INFORMATION: <br />a. locadon (address): ~~5 ~-n~21' ~? i.l~ ~,t'r.M <br />b. D~awing of Encroachment (show right-of-way, dimensions of a~ea, north arrow, etc.): <br />c. Legal Uescription of Encroachment Area (please attach): <br />d. Area of Encroachment: 1~ ft. by I•~ ft. = 21?.4 squa~e feet <br />e. ~ Purpose of Encroachment: ,~L~.~. ~tt~ d...l~ ~,~~~.~ ~~ ~- ~v~~ Z~~~L~.~c, <br />APPUCATION FIUNG FEE: (circle one) ~ <br />~ PertnanenUFxed lstructures such as footings, awnings, u~derground utilities) 8324 fee PID No. 65832.202 <br />~6 Temporary/Nonfixed (fences, parking areas) 5324 fee PID No. 65832.203 <br />4. REaU1RE0 ATTACHMENTS: • <br />Attac~ copy of plans, specifications, site pla~, etc., sufficient to identify encxoachme~t and area involved. Allow for <br />one week processi~g if infortnation ~s complete. <br />5: PERMIT CONOITIONS: <br />1 understand that 'rf granted, the permit will be subject to the following conditions: <br />a. Encxoachment to be maintained in good order. <br />b. Payment of an annual fee o~ a one-time fee, depending upo~ the type of encroachment. <br />c. 1 may be required by the City of Salem at some future date to remove the encroachment at my expense. <br />d. The e~c~oachment permit will not relieve me of my ~espo~sibility to obtain and/or abide by other pennits, <br />codes, s~d ordinances of the City of Salem. <br />e. I will be responsible for any inhaction arising out of the encroachment being placed within the public <br />right-of-way. <br />f. All worlc shall be done in accordance with all applicable provisions of federal, state and local law, ordinance and <br />administrative ~ule. <br />g. All work i~ puWic right-of-way and all work which is connected, directly or indirectly, to City of Salem wate~, <br />• sanitary sewer or storm sewer lines shall be constructed i~ accordance with applicable City of Salem Standard <br />Construction Specifications. <br />h. Permittee shall indemnify, defend and save harmless the City of Salem, its office~s, employees and agents from <br />any and all claims arising out of or in connection with any work done u~der this permit. <br />~-4-~s <br />Date <br /> <br />Check S Check # Cash S Billed S P.O.# Rec'd: / / BY: <br />Original-Traffic, Copy 1-Applicant, Copy 2- Finance-Misc. Receipts PAC02.FOR 06/10/98 <br />