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t. <br /> City of Eugene <br /> Public Works <br /> Application for Public Improvement Permit Engineering <br /> 858 Pearl Street <br /> Job Number: Eugene, OR 97401 <br /> (541) 682-5291 <br /> FAX: (541) 682-5032 <br /> Contract No: , ~j~~ C ~ v~1 <br /> I, ~ F~CGJCJ/ / hereby make application for a PUBLIC IMPROVEMENT PERMIT to <br /> (owner) <br /> construct public improvements in the public way, as described below: <br /> r <br /> Type of Improvement: G r <br /> (paving, s ewater, stonnw er, street lights) <br /> Location: y ~3~uleUc~Yd aid ~e~~~ ~f~~~~d~ <br /> ' ~J (street~o~rleasement work is within or subdivision name) ` / /J ' 'l <br /> North (or east) limit: ROt~2 V'CX~i ~ D ~~iJ South (or west) limit: f~~~V ~ ~~-U <br /> in strict conformance with City of Eugene standard specifications for public improvements (including current addenda); <br /> construction plans approved by the city engineeror 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 permCitt~o the contractor performing the work. <br /> Contact Pe on (pdrm 1\ `r° I~ ~~~c~Ul~ <br /> Signatu a Mailing Address n • 'V / 'T"~ <br /> Print signet re here ~'n <br /> Date 4 r2. ~ Phone 5~ I' ~ ~ ~ ' 4'II City /State /Zip ~ ~ <br /> Z~ <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: Date: <br /> City Engineer <br /> <br /> Enq: 604 FEBRUARY 2002 <br /> White: Owner/Designer Canary: Contractor Pink: Inspector <br /> <br />