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City of Salem <br />P~blic Works Department <br />Traffic Engineering Division <br />555 Liberty Street SE, Room 325 <br />Salem, Oregon 97301-3503 <br />lephone: (503) 588-6211 <br />: (503) 588-6292 <br />. <br />~ cit~/of Salem <br />• ~ 588•6256 <br />~ <br />(Pem'~it app~Cation centet) <br />REVOCABLE PUBLIC RIGHT-OF-WAY <br />ENCROACHMENT PERMIT APPUCATION <br />PID No. <br />Filing Fee 5324.00 <br />Automation Fee 5 2.50 <br />Processing Fee 5 7.50 <br />Total S 334.00 <br />Application No. <br />APPLICATION FOR PUBLIC RIGHT-OF-WAY ENCROACHMENT REVOCABLE PERMIT AGREEMENT <br />REFERENCE SRC 76.160, 76.i65 <br />1. <br />2. <br />4. <br />5: <br />APPUCANT INFORMATION: <br />Name: <br />Addres: <br />Telephone (business): 58~8 ~-.~'~ 588-24Z~ (home) <br />r..o.s cca~...+~y. ~Tt~ ~ <br />ENCROACHMENT INFORMATION: <br />a. Location (address): '~`^J' S ~a~~r c.~S ~ ~~ <br />b. Orawing of Enc~oachment (show right-of-way, dimensions of a~ea, north anow, etc.): <br />c, legal Description of Enc~oachment Area (please attach): <br />d. Area of Encroachme~t: " L~ ft. by _~_ ft. = I Z Z square feet <br />e. ~ Purpose of Encroachment: 1'.~• <<y=~~_ Z$~if ~~l~vJ'De~ ~'~S ~E~L- Put1~__~Z.o•\Y. <br />APPUCATION FILING FEE: (circle one) ~ <br />~ Pertnanent/Fixed (structu~es such as footings, aw~ings, underground utilities) 5324 fee PID No. 65832.202 <br />"'S TemporaryMonfixed (fences, parking areas) 5324 fee PID No. 65832.203 <br />REQUIRED ATTACHMENTS: • <br />Attach copy of pla~s,,spe~cations, site plan, etc., sufficient to identify encroachment and area involved. Allow for <br />one week processing ~f information ~s complete. <br />PERMIT CONDITIONS: <br />1 understand that if granted, the pennit will be subject to the followi~g conditio~s: <br />a. Encroachment to be maintained in good order. <br />b. Paymerrt of an a~nual fee or a one-time fee, depending upo~ the type of encroachme~t. <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 encroachment pennit 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. 1 will be respo~sible for any i~fraction arising out of the encroachment bei~g placed within the public <br />~ight-of-way. <br />f. All work shall be done in accordance with all applicable provisions of federal, state and local law, ordinance a~d <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 />• sanitary sewer o~ stonn sewer lines shall be constn.icted 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 or in connectio~ with any work done under this permit. <br />~ -9 -~~ <br />Date <br />Check 5 Check # ~ Cash $ Billed S P.O.# Rec'd: / / BY~ <br />Original-Traffic, Copy 1-Applicant, Copy 2- Finance-Misc. Receipts PAC02.FOR 06/10/98 <br />