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City of Salem REVOCABLE PUBLIC RIGHT-OF-WAY <br />Public Works Department ~• ENCROACHMENT PERMIT APPLICATION <br />T~affic Engineering Division ~Qf Sa~m <br />555 Liberty St~eet SE, Room 325 ~~QQ•6256 P~D No. <br />Salem, Oregon 97301-3503 ~ ~~v <br />elephone: (503) 588-6211 ~ Fling Fee 5324.00 <br />:(503) 588-6292 N~~ ~ation c~te~~ Automation Fee 5 2.50 <br />Processing Fee S 7.50 <br />Total 5334.00 <br />Application No. <br />APPLICATION FOR PUB~IC RIGHT-OF-WAY ENCROACHMENT REVOCABLE PERMIT AGREEMENT <br />REFERENCE SRC 76.160, 76.165 <br />1. APPUCANT INFORMATION: <br />Name: ~d.~101.1 r~t.lwtlzl ~ ~J~.F-.~ d~~ u-~b55 'Ti2.~.~sa 1~sT~cat. <br />Add~ess: I Gt~ ~{ IG, K ST t~1 E 5~i.~~+ ~ 97301 361~ ~~ 31 ~+D l~l ~ilF~f.f~ ,[~1~ ~.3~ ~ Oe. <br />Telephone (business): HG •Sf-R ~~55 ~~•*T~o 5t~-24?r4(home) <br />2. ENCROACHMENT INFORMATION: <br />a. Location (address): r/'S5 ~ac.e2T ST t~•~• ~^1 ~-~"~ ~ °~7~0~ <br />b. ~rawing of Encroachment (show right-of-way, dimensions of area, north arrow, etc.1: <br />c. Legal Description of Encroachme~t Area (please attach): <br />d. Area of Enc~oachme~t: ~_ ft. by ~_ ft. = Z31 square feet <br />e. ~ Purpose of Encroachme~t: `~~~'TM' ' G°d~~~ ~x ~~~ s~~~ ~~'~- <br />APPUCATION FILING FEE: (circle one) ~ <br />,~ Pertna~e~~xed (stnictures such as footings, aw~ings, underground utilities) 8324 fee PID No. 65832.202 <br />Temporary/Nonfixed (fences, pa~king areas) 5324 fee PID No. 65832.203 <br />4. REaU1RED ATTACHMENTS: ~ • <br />Attach copy of plans,,specifications, site plan, etc., sufficie~t to identify encroachment and a~ea i~volved. Allow for <br />one week processing ~f ~nfonnation ~s complete. <br />5: PERMIT CONDITIONS: <br />I understa~d thet if granted, the peRnit will be subject to the following conditions: <br />a. Encroachment to be maintained in good orde~. <br />b. Payment of an annual fee o~ a one-time fee, depending upon the type of encroachment. <br />c. I may be required by the City of Salem at some future date to remove the e~croachment at my expense. <br />d. The encroachment pertnit will not relieve me of my responsibility to obtain and/or abide by other permits, <br />codes, and ordinances of the City of Salem. <br />e. I will be ~esponsible for a~y infraction arising out of the enc~oachment being placed within the public <br />right-of-way. <br />f. All work shall be done in accordance with all applicable provisions of federal, state and local law, ordinance and <br />administrative rule. <br />g. All work in public right-of-way and all work which is connected, directly o~ indirectly, to City of Salem water, <br />• sa~itary sewer or storm sewer lines shall be constructed in accordance with applicable City of Salem Standard <br />Construction Specifications. <br />h. Permittee shall indemnify, defend and save harmless the City of Salem, its officers, employees and agents from <br />any and all claims arising out of o~ in con~ection with any work done under this permit. <br />c~~,,~ a-~-s~ <br />Signatu f Applicant Date <br />Check $ Check # Cash 5 Billed S P.O.# Rec'd: / / By: <br />Original-Traffic, Copy 1-Applicant, Copy 2- Finance-Misc. Receipts PAC02.FOR 06/10/98 <br />