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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 <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 URIED 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 I I 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: AMOUNT OF BOND <br /> 1820 Roosevelt Blvd. OAR 734-55 0 <br /> YES J NO 035(2) <br /> Eugene, OR 97402 I INSURANCE REFERENCE SPECIFIED COMP. <br /> Attn: Bonnie Beck YES I J I NO OAR035(1)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 YES [OAR 734-55-025(6)1 J NO 2 YES [OAR 734-55-100(21 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 COPY 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 <br /> APPLICANTAPPLIC TION DATE TITLE TELEPHONE NO. <br /> �G/(oJ�� A4141444A/if <br /> 8 79(0 <br /> When this application is approved by the Department,the applicant is subject to,acc pts and approves DISTRICT MANAGER OR REPRESENTATIVE APPROVAL DATE <br /> the terms and provisions contained and attached:and the terms of Oregon Administrative Rules, <br /> Chapter 734,Division 55,which is by this reference made a part of this permit. X <br /> 734-3457(10-95) <br />