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,~--°°s PERMIT NUMBER <br />O1iaonDip"~"'°'"~°~~Oi"""0M APPLICATION AND PERMIT TO OCCUPY OR <br />~~~~~r PERFORM OPERATIONS UPON A STATE HIGHWAY <br />Sae Oregon Administrative Rule, Chapter 734, Divi~an 55 CLASS : a5 ftEY# <br />GENERAL LOCATION PURPOSE OF APPLICATION <br /> ITO CONSTRUCTIOPERATEIMAINTAINI <br />HIGHWAY NAME AND ROUTE NUMBER POLE <br />^ LINE TYPE III~N. VERT, CLEARANCE <br />PACIFIC HIGHWAY 1 ~I-5} NIA w <br />HIGHWAY NUMBER COUNTY DRIED TYPE <br />001 20 =LANE CABLE NIA <br />BETWEEN OR NEAR LANDMARKS PIPE <br />^ LINE TYPE <br />BELTLINE HIGHWAY AND SPRAGUE ROAD NIA <br />HWY. REFERENCE MAP DESIGNATED FREEWAY IN U.S. FOREST NON-COMMERCIAL <br />^ FEE AMOUNT <br /> <br />88-214 <br />®YES ^ NO N <br />^YES ® 0 SIGN 0.00 <br />APPLICANT NAME AND ADDRESS ®t~SCELLANEOUS OPERATIONS ANDIOR FACILITIES AS <br />CITY OF EUGENE PUBLIC WORKS DESCRIBED BELOW <br />ATTN: JENFIER WILLER, P.E. FOR oDOT USE 0 <br />BOND REQUIRED REFERENCE; LY <br />AMOUNT OF BOND <br />244 EAST BROADWAY OAR 734-55 <br />^YES ®N0 <br />$0 <br />40 <br /> a3~~~, . <br />EUGENE, OR. 9?401 ~ INSURANCE REQUIRED REFERENCE; SPECIFIED COMP, DATE <br /> X541} fi82-53fi4 ®YES ^ NO OAR 734.55 1!0112009 <br /> a~5 ~ <br />DETAIL LOCATION OF FACILITY~For more space attach additional sheets <br />MILE MILE ENGINEERS ENGINEERS s1°~ °~ ~~' °~ DISTANCE FROM BURIED CABLE OR PIPE SPAN <br />POINT . TO POINT STATION TO STATION ANGLE OFCR°SSING ENTER OF PVM RIW LINE DEPTHNERT. SIZE AND KIND LENGTH <br />195.79 423+6p BOTH SEE ATTAC CONSTRU TION PLAN <br />t <br />3 <br />i <br />DESCRIPTION AND LOCATION OF NON-COMMERCIAL SIGN5 OR MISCELLANEOUS OPERATIONS FACILITIES <br />PERMIT iS FOR CITY OF EUGENE PROJECT WITHIN ODOT RIGHT OF WAY, PROJECT # 4326, FED. AID PROJECT <br /># STP-2385-3057), ODOT i~EY # 15524 <br />SPECIAL PROVISIONS (FOR MORE SPACE ATTACH ADDITIONAL SHEETSI <br />TRAFFIC CONTROL REaUfRED -OPEN CUTTING OF PAVED OR SURFACED AREAS ALLOWED? <br />• ® YES SOAR 734-55-025(fil~ ^ NO i ^ YES [OAR 734-55-1002] ® NO SOAR 734-55-100111 <br />• AT LEAST 48 HOURS BEi^ORE BEGINNING WORK, THE APPLICANT DR HIS CaNTRACTOR SHALL NOTIFY THE DISTRICT REPRESENTATIVE <br />AT TELEPHONE NUMBER: ~ 541 y 656-7626 <br />QR FAX A CQPY OF THIS PAGE TO THE DISTRT~T~I"'~: N~q SPECIFY TIME AND DATE IN THE <br />SPACE BELOW. <br />~ A COPY OF THIS PERMIT AND ALL ATTACHMENTS SHALL BE AVAILABLE AT THE WORK AREA DURING CONSTRUCTION. <br />~ ATTENTION: Oregon Law requires you to follow rules adopted by the Oregon Utility Notification Center. Those rules are set forth in UAR <br />952-001-0010 through OAR 9b2-001-0090. You may obtain copies of the rules by calling the center st X5031232-1887. <br />CAt~ BEFdRF YaU D1G ~-84DL332-2344 <br />COMMENTS - ODOT USE ONLY <br />PERMIT & PERMISSION TO WORK WITHIN ODOT RIGHT OF WAY AT ABOVE LOCATION. PERMITTEES WORK SHALL IN <br />NO WAY [NTERFERE WITH THE ODOT BELTLINE & I-5 CONTRACTOR ~MOWAT}. ANY CHANGES IN CONSTRUCTION <br />PLANS WITHIN ODOT RIGHT OF WAY NEED TO BE APPROVED PRIOR TO CONSTRUCTION BY ODOT. WORK TO BE DONE <br />IS ON NORTH GAME FARM RD. UNDER THE I-5 OVERHEAD IN ODOT RIGHT OF WAY. <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 O~FI I L SIGNATURE TITLE DATE <br />X ~ <br />APPI,ICA T SIGN RE ~ APPLICATION DATE TITLE TELEPHONE N0. <br />~ ~. o g ~ ~ <br />~ ~ <br />When this ap i tion is ap by the Department, the applicant is subject to, accepts and approves DISTRICT MANAGER OR REPRESENTATIVE APPROVAL DATE <br />the terms a visEons contained and attached: ar~d the terms of Oregon Administrative Rules, <br />~Fiapter 734, pivi~on 55, which is by this reference made a part of this permit. <br />734-3457(1-Ofi) <br />