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C'Ity of Eugene <br /> Public Works <br /> <br /> 1 ' plication for ublic Improvement Permit Engineering <br /> 858 Pearl Street <br /> J~b Number: ~5 ~ Eugene, OR 97401 <br /> (541) 682-5281 <br /> FAX: (541)682-5032 <br /> Contract N <br /> 1 <br /> I', hereby make application for a PUBLIC IMPROVEMENT PERMIT to <br /> lid <br /> I c nstru p lic imp vements In the public way, as described below: <br /> Type of Improv ment: GJ ~ ~ +'e w FlT!"~ L,w,~ I ~~`f WW ~ ~~it.J,51 QVl <br /> (patAng, wastewater, storrnwater, street Hghtsj <br /> i II <br /> Location: <br /> (street or easement work is within or subdivision name) <br /> North (or east) imit: South (or west) limit: W + LsN fZa?4J <br /> i <br /> in strict conforrnan with City of Eugene standard specifications for public improvements (including current addenda), <br /> i <br /> ~ construction plans proved by the city engineer or his representative, the current edition of "Procedures for Privately Engineered <br /> projects "the Euge a City Code, and the standard and special conditions printed on this permit form. The owner/applicant is <br /> tesponsible for pro iding a copy of this permit to the contractor perforating the work. <br /> contact Person tP~ It ~ ~ ~ S <br /> ~ ~fo~D C~.s~e~Iv~ Ati~ <br /> Signature _ Mailing Address <br /> 'Print signatu her <br /> 'Date Z ? O Phone 7/ City /State /Zip ©r ~ 7~D$ <br /> DO NOT YYRRE BELOW THIS LINE <br /> PUBLIC IMPROVEMENT PERMIT <br /> Permission is he y granted to applicant and applicants contractor to perform the work stated above, in conformance with <br /> conditions listed ve, below, and on the reverse side of this permit form. <br /> ~ ;The permit shall void unless the work described herein is completed by: <br /> SPECIAL CONDI IONS <br /> I <br /> I <br /> APPROVED: Date: <br /> i City Engineer <br /> i <br /> i <br /> i <br /> ~a~ B04 FEBRUARY 1042 <br /> Whlta: Ov+nedDeetpnar Canary: Contractor Ptnk: Inspector <br /> <br />