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City of Safem ~
<br />Public Works Department ~
<br />Transportation/Development Management Division ~~ Salem
<br />555 Liberty Street SE, Room 325 ~~5$$•6256
<br />Salem Oregon 97301-3503 ~
<br />STREET/LANE/ALLEY/SI DEWALK
<br />CLOSURE PERMIT
<br />PID No.
<br />65832.205
<br />~ner~r~t a~at~«, c~,te~~ Permit Fee $29.50
<br />Telephone: (503) 588-6211 Processing Fee ~/O QQ ~g~
<br />TTY: (503) 588-6292 Total Payment 3~'~~Q ~
<br />48 HOURS NOTICE REQUIRED-WEEKENDS EXCLUDED /
<br />Permit No. ~ - 1 (`j
<br />APPLICATION FOR: ^ Street Closure ^ Lane Closure ^ Alley Closure ,~ Sidewalk
<br />Street: _~a,-.~~ COU ~lt~ C:U t~`,' C-~v('~ f~~-~i ~~1/1C l< F-/ /~~ C I-1 ~'JTCr~ ~ J-~ ~ C-~ f-~
<br />Location: ~Z~ ~ ~ l ;~-, F~ ~J i ~ ~ ~ ~
<br />APPLICANT: Day Phone:
<br />Address: Evening Phone:
<br />Applicant is contractor? ~ Yes ^ No
<br />CONTRACTOR: ,jT.rq r~~ / ~~,f~o~-T- Tit/~" Day phone: _.~5~~- 5~// -655~~
<br />Address: _ --~ ~'.39~- ,~ ~/,Q/~0,~'T ~,~ ~tJ6'~/~ ~'L~ S7~10~ Evening phone: ,~c/% yS~i,1'~577
<br />Contractor's Contact Person: i~l,4~~ ~,~~~ ~ Day phone: ~~ ~`~77 Evening Phone: YS ;l ~97~
<br />^ Street Opening Permit No: ^ City Project No.: ,~ Private Contract
<br />Request date and time of closure:
<br />Description of work to be done: ~ ° ~,~,. ~ ~ 'i ~ ~ n ~~-, ~ ~ ~. ~ ~~ ~ ~ P ~ -- ~ ~,~ `l ~- '~,~ ~ L~
<br />1. Permittee shaii follow the signing requirements of the City of Salem's "Traffic Control Manual for Maintenance and Construction" and
<br />any other traffic control requirements as needed or specified.
<br />__'. Ali work shall be done in accordance with all applicable provisions of federal, state and local law, ordinance and administrative rule.
<br />3. All work in public right-of-way and all work which is connected, directly or indirectly, to City of Salem water, sanitary sewer, or storm
<br />sewer lines shall be constructed in accordance with applicable City of Salem Standard Construction Specifications.
<br />4. For extended closures lasting over one day, Contractor shall notify the Emergency Communications Center at 588-6123 each day
<br />prior to street closure.
<br />5. Permittee shall indemnify, defend and save harmless the City of Salem, its officers, empioyees, and agents from any and all ciaims
<br />arising out of or in connection with any work done under this permit.
<br />6. This permit may be revoked at any ti e by the-Director of Public Works or his designee.
<br />~ Signature of Applicant: _ ~!/i.T%~ .(f/ .- -_°~C~ Date: _ .~~~ ~'~9 ~
<br />The (Street) (Lane) (Alley~ (Sidewa Closure indicated above is approved subject to the following additional conditions:
<br />~'O i ~ ht~ 1 O f ~ ~°~' :~ f ~t, ~`f''? '1~ u,.,.~) _ l ~c n ~ ~ u'~~P ~ ~ v~ ~~ ~ '~n r'
<br />~~n~ f C ', ' ~. ~f' ^, I.. r~j n c P `j ~a ~S a '` ~~u~ v~ ~~ ^ F~. u r2 1
<br />~C l~n ~Y~ ~ ~ ~
<br />. ~ ,~ /
<br />~~' ,~ ~ ~
<br />Permit Approved By: ~7Si// - , ~~ ~!i ,~Date: "J~ / /9/ ~7
<br />, - - 1 .
<br />Check S Check # Cash $ Bilied $ PO # Rec'd by: / / gy;
<br />White-Traffic, Yellow-Applicant, Pink-~nspector;
<br />Additional copies: Parking Enforcement, PW Dispatch PW:PAC03.FOR O6/13/96
<br />Date of Closure: From: _.~~ 2-2.-. To: ~/ Z. L
<br />~
<br />Time of Closure: From: ~ ~~ ~~ ~ ~n ~)~~ ~~ To:
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