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APPLICATION AND PERMIT TO OCCUPY OR PERMIT NUMBER <br /> PERFORM OPERATIONS UPON A STATE HIGHWAY <br /> See Oregon Administrative Rule,Chapter 734, Division 55 05M 3 6 0 2 2 <br /> .GENERAL LOCATIONPURPOSE OF APPLICATION <br /> (TO CONSTRUCT/OPERATE/MAINTAIN) <br /> HIGHWAY NAME AND ROUTE NUMBER POLE TYPE MIN.VERT. CLEARANCE <br /> LINE <br /> Eugene - Springfield Highway <br /> HIGHWAY NUMBER COUNTY BURIED TYPE <br /> 227 20 = LANE !CABLE <br /> BETWEEN OR NEAR LANDMARKS PIPE TYPE <br /> 1st Ave. and 7th Ave. LINE <br /> HWY. REFERENCE MAP DESIGNATED FREEWAY IN U.S. FOREST <br /> As Const Bridge 27305 J YES NO YES J NO NON-COMMERCIAL SIGN <br /> APPLICANT NAME AND ADDRESS MISCELLANEOUS OPERATIONS AND/OR <br /> City of Eugene Public Works J FACILITIES AS DESCRIBED BELOW <br /> Park Facilities BOND REQUIRED REFERENCE: I AMOUNT OF BOND <br /> 1820 Roosevelt Blvd. YES Ri NO OAR 734-65 I 0 <br /> 035(2) <br /> Eugene, OR 97402 INSURANCE REFERENCE SPECIFIED COMP. <br /> Attn: Bonnie Beck YES I J I NO 035(1)OAR 734-55 <br /> DETAIL LOCATION OF FACILITY(For more space use back of application or attach additional sheets) <br /> MILE MILE ENGINEERS ENGINEERS SIDE OF HWY OR DISTANCE FROM BURIED CABLE OR PIPE SPAN <br /> POINT TO POINT STATION TO STATION ANGLE OFCROSSING CENTER OF PVMT R/W LINE DEPTH/VERT. SIZE AND KIND LENGTH <br /> Bent L-3 L80+ 10 <br /> Bent L-4 L81 +76 <br /> SPECIAL PROVISIONS (FOR MORE SPACE ATTACH ADDITIONAL SHEETS) <br /> TRAFFIC CONTROL REQUIRED - OPEN CUTTING OF PAVED OR SURFACED AREAS ALLOWED? <br /> 1 L YES [OAR 734-55-025(6)1 J NO 2 YES[OAR 734-55-100(2] J NO (OAR 734-55-100(1) <br /> 3 WITHIN 48 HOURS BEFORE BEGINNING WORK AND AFTER COMPLETING THE PERMIT WORK,THE APPLICANT OR HIS CONTRACTOR SHALL NOTIFY <br /> THE DISTRICT REPRESENTATIVE AT TELEPHONE NUMBER: 726-2552 OR RETURN THE ATTACHED POSTCARD. <br /> 4 A COPY OF THIS PERMIT AND ALL ATTACHMENTS SHALL BE AVAILABLE AT THE WORK AREA. <br /> 5 ORS 757.54 TO 757.571 REQUIRES EXCAVATORS TO LOCATE AND PROTECT ALL EXISTING UNDERGROUND UTILITIES.YOU MAY BE HELD LIABLE <br /> FOR DAMAGES.CALL FOR UTILITY"LOCATES.CALL BEFORE YOU DIG. <br /> 6 A CJPY OF THIS PERMIT MAY BE FAXED TO THE DISTRICT OFFICE(FAX# AS NOTIFICATION OF INTENT TO BEGIN WORK <br /> SPECIFY DATE AND TIME TIME DATE <br /> SEE REVERSE SIDE FOR SPECIAL PROVISIONS. <br /> COMMENTS THIS PERMIT IS FOR ACTIVITIES UNDER HIGHWAY 227, SPECIFICALLY MURAL PAINTING ON BRIDGE <br /> SUPPORTS. <br /> IF THE PROPOSED APPLICATION WILL AFFECT THE LOCAL GOVERNMENT, THE APPLICANT SHALL ACQUIRE THE LOCAL GOVERNMENT <br /> OFFICIAL'S SIGNATURE BEFORE ACQUIRING THE DISTRICT MANAGER'S SIGNATURE. <br /> LOCAL GOVERNMENT OFFICIAL SIGNATURE TITLE DATE <br /> X APPLIC TION DATE TITLE TELEPHONE NO. <br /> APPLICANT 6 /1014444,4- S g <br /> When this application is approved by the Department,the applicant is subject to,acc pts and approves DISTRIC;fAANAGER OR R/JEPRES TIVE APPROVAL <br /> D TE <br /> the terms and provisions contained and attached:and the terms of Oregon Administrative Rules, I J <br /> Chapter 734,Division 55,which is by this reference made a part of this permit. X ,� �77 %:— <br /> 734-3457(10-95) <br />