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City of Salem Public Works Department Transportation/Development Management Division 555 Liberty Street SE, Room 325 Salsm, Oregon 97301-3503 Telephone: (503) 588-6211 TTY: (503) 588-6292 ~ ~SalelYt • ~ 85 8•6256 N~~t~t~,~,~, STREET/LANE/ALL Y/SIDEWALK CLOSURE PERMIT PID No. 65832.205 Permit Fee $29.50 Processing Fee ~/D,DO --~56~- Total Payment 3~', ~4 ~ 48 HOURS NOTICE REQUIRED-WEEKENDS EXCLUDED Permit No. ~ ' ~ APPLICATION FOR: ^ Street Closure ^ Lane Closure ^ Alley Closure ,ra Sidewalk Street: ~~-,<< ~O~) ~ll~ tU ~`~ ~-f1U(~~ I I~ 1~~~=N1 c l~ ET~~ C- (~IIJT C.r-~~~ J-~ J C-,1-~ Location: ~Z.~ t f 1`-~ ~~ S~ ~ ~- APPLICANT: Address: Applicant is contractor? ~Yes ^ No Day Phone: Evening Phone: CONTRACTOR: S7~ 7"/3~' ~ ~/~,r,~~'7~ T~~ Day phone: .~5~~' S~~/ ~ds5~.~ Address: -~ `~~y~- ~ ~~~/~4~T ~~ ~~E~i ;~r~ /%,~ . J~7~OZ,. Evening phone: .Sc!/- YfS~'~5~7'7 Contractor's Contact Person: i~///~~ . S7'AJ'ry+ ~ Day phone: 9~ ~4?7 Evening Phone: YS`5~ ~97~ ^ Street Opening Permit No: ^ City Project No.: ~ Private Contract Request date and time of closure: Description of work to be done: ~ ° ~~.. ~ ~ ~~ '~~~ n ~~ '`~ ~ ~' `- ~~ ~~, ~~%'~ ' ~ ~~ ~t ~ ~'~ fi L~ 1. Permittee shall follow the signing requirements of the City of Salem's "Traffic Control Manual for Maintenance and Construction" and any other traffic control requirements as needed or specified. 2. All work shall be done in accordance with all applicable provisions of federal, state and local law, ordinance and administrative rule. 3. All work in public right-of-way and all work which is connected, directly or indirectly, to Ciry of Salem water, sanitary sewer, or storm sewer lines shall be constructed in accordance with applicable City of Salem Standard Construction Specifications. 4. For extended closures lasting over one day, Contractor shall notify the Emergency Communications Center at 588-6123 each day prior to street closure. 5. Permittee shall indemnify, defend and save harmless the City of Salem, its officers, employees, and agents from any and all claims arising out of or in connection with any work done under this permit. 6. This permit may be revoked at any ti e by the-Director of Public Works or his designee. ~f, Signature of Applicant: G~//~ ~% - ~ Date: .S/ ~ ~~9 ~ f. ~=-z - - . The (Street) (Lane) (Alley~ ( iS dewa Closure indicated above is approved subject to the following additional conditions: . ~ r ( t- ~~- 1 ' ,~ ~ ~5 C Or' ~' ~7 ~ 1 hl. 1 Q~ 1 !" :.:'/'. ? f Q~ ~ l/~~ CLv. !_ ~ C' n~ ~ U i P c v~ ~. ; v `~ ~jf ~ c.~ ~ 1~'~ u r2 1, _S-. r_~~ '.. I ~. '~-r- E. ~_ ! 1 n r A ~"~ 1 q ~n5 Q ~~? C.L.J ~/~ i:.~ ~- PermitApproved By: ~~~,3,!~l~ %- / -+~i'~ ~'~~ ~D te: ~ / ~9/ 7 ? Check S Check # Cash $ Billed $ PO # White-Traffic, Yellow-Applicant, Pink-Inspector; Additional copies: Parking Enforcement, PW Dispatch Rec'd by: / ~ BY~ PW:PAC03.FOR 06/13196 Date of Closure: From: .~/ 2-Z- To: ~~~Z- ~ Time of Closure: From: ~~; n'~ 1 s~ r 1 r' ~ t~ To: