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I <br /> ~ 5 A <br /> ' City of Eugene <br /> Public Works <br /> AppMication for ublic Improvement Permit Engineering <br /> 2 858 Pearl Street <br /> 'Job Number: 53 Eugene, OR 97401 <br /> (541) 6$2-5291 <br /> FAX: (541) 682-5032 <br /> Contract No: <br /> I, hereby make application for a PUBLIC IMPROVEMENT PERMIT to <br /> (owrrer) <br /> construct public impr vements in the public wa-y, asdes/c~ribed below: t ~ J A <br /> Type of Improve ent: ~ 'v ` t , ` ~ Y v <br /> (paving, wastewater, storrnwater, street lights) <br /> Location: r ~ wr d <br /> (street or easement work is within or subdivision name) <br /> North (or east) li it: South (or west) limit: <br /> i <br /> ins strict conforman with City of Eugene standard specifications for public improvements (including current addenda), <br /> construction plans roved by the city engineer or his representative, the current edition of "Procedures for Privately Engineered <br /> Projects," the Eugen City Code, and the standard and special conditions printed on this permit form. The owner/applicant is <br /> responsible for provi ing a copy of this permit to the contractor performing the work. <br /> ~n~~ <br /> Contact Person cn~~n ~ ' I~'I <br /> S~gnature ~ Mailing Address ss ~33 / r~L'~e,~~, P if <br /> i,J <br /> v <br /> Print signs ure here rU e ~i ~ N ? ~l~ ~ % <br /> Dlate Phone ~Z~'~~'~ City /State /Zip <br /> cel( ?zq-(~Ty <br /> DO NOT WRrTE BELOW THIS UNE <br /> PUBLIC IMPROVEMENT PERMIT <br /> Permission is hereb granted to applicant and applicants contractor to perform the work stated above, in conformance with <br /> condftions listed ab e, below, and on the reverse side of this permit form. <br /> The permit shall be oid unless the work described herein is completed by: <br /> SPECIAL CONDITI NS <br /> APPROVED: Date: <br /> City Engineer <br /> i ~ <br /> I <br /> <br /> EOg 604 FEBRUARY 2002 <br /> ~ while: OwnedDesigner Canary: Contractor Pink Inspector <br /> <br />