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? 1 • f'I <br /> City of Eugene <br /> Public Works <br /> Application fa`'r Public Improvement Permit Engineering <br /> ~d 858 Pearl Street <br /> Job Number: ~ ~ ~ W'"~ Eugene, OR 97401 <br /> (541) 682-5291 <br /> FAX: (541) 682-5032 <br /> Contract No: <br /> I, eSOi~ hereby make application for a PUBLIC IMPROVEMENT PERMIT to <br /> (owner) <br /> construct public i provements in the public way, as/describe^d/below: l <br /> Type of Improvement: ~uJ ~l G ~~i(.PT Q/'t U' S~lJrm ~r'Q.~/)~ I~Q~/Pl~ t'~'1-T S <br /> (paving, wastewater, stonnwater, street lights) <br /> d52 ~ <br /> Location: <br /> (street or easement work is n or subdivision name) <br /> North or east limit: ~DO~SI°!/ O u/ South or west limit: <br /> 'n strict conforms I ce with City of Eugene standard specifications for public improvements (including current addenda), <br /> onstruction plans pproved by the city engineer or his representative, the current edition of "Procedures for Privately Engineered <br /> rojects," the Eug ne City Code, and the standard and special conditions printed on this permit form. The owner/applicant is <br /> )•esponsible for pro iding a copy of this permit to the contractor performing the work. <br /> (Contact P rson (P~ ~~ecSd n <br /> ignatu~ ~ Mailing Address P•o • ~ <br /> Tint sign ture her c ~1 <br /> ate 2 _ Phone City /State /Zip G~'LY1 P ~ "1 <br /> I <br /> DO NOT WRITE BELOW THIS LINE <br /> j i PUBLIC IMPROVEMENT PERMIT <br /> permission is here y granted to applicant and applicant's contractor to perform the work stated above, in conformance with <br /> Conditions listed a ve, below, and on the reverse side of this permit form. <br /> lfhe permit shall be void unless the work described herein is completed by: <br /> PECIAL CONDIT ONS <br /> (APPROVED: Date: <br /> City Engineer <br /> <br /> EnQ: 604 FEBRUARY 2002 <br /> White: OwneNDesigner Canary: Contractor Pink: Inspector <br /> <br />