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,: <br />Application for Public Improvement Permit <br />City of Eugene <br />Public Works <br />Engineering <br />Job Number: <br />858 Pearl Street <br />Eugene, OR 97401 <br />(541) 682-5291 <br />FAX: (541) 682-5032 <br />Contract No: <br />I, /~~ ~ `~ e~~~ hereby make application for a PUBLIC IMPROVEMENT PERMIT to <br />(owner) <br />construct public improvements in the public way, as described below: <br />Type of Improvement: <br />(paving, wastewater, stormwater, street lights) <br />Location: <br />(s~tr~e"et)or easement work is wl'85in or subdivision name) I // <br />North (or east) limit: DO~SPI/ ~ D u/ South (or west) limit: _~D~e ~~X~ ~ U <br />in strict conformance with City of Eugene standard specifications for public improvements (including current addenda), <br />construction plans approved by the city engineer or his representative, the current edition of "Procedures for Privately Engineered <br />Projects," the Eugene City Code, and the standard and special conditions printed on this permit form. The owner/applicant is <br />responsible for providing a copy of this permit to the contractor performing the work. <br />Contact Person (piing ~!~ ~~e~~ <br />Signature <br />Print sign ture here ~`n ~,Sar. <br />Date _~ ~Z ~D $ Phone _ ~J4~ - ~' ~ -Z~ <br />Mailing Address_ ~.~ • ~U~ ~ ~ `~~ <br />City /State /Zip ~uA~.YI _ D '~ ~ 4`T~ <br />DO NOT WRITE BELOW THIS LINE <br />PUBLIC IMPROVEMENT PERMIT <br />Permission is hereby granted to applicant and applicant's contractor to perform the work stated above, in conformance with <br />conditions listed above, below, and on the reverse side of this permit form. <br />The permit shall be void unless the work described herein is completed by: <br />SPECIAL CONDITIONS <br />APPROVED: <br />City Engineer <br />Date: <br />Eng: 604 FEBRUARY 2002 <br />WhRe: Owner/Designer Canary: Contractor Pink: Inspector <br />