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I <br /> • ~ City of Eugene <br /> <br /> • Public Works <br /> /#pplication far 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: ' ) <br /> I, ~ ereby make application for a PUBLIC IMPROVEMENT PERMIT to <br /> (owner) <br /> construct public Irrlprovements in t e public way, as described below: <br /> Type of Improvement: ~~~-WA~~ <br /> (paving, wastewater, stonnwater, street lighffi) <br /> (1~~ ebPl~ <br /> Location: <br /> (street or easement work is within or subdivision name) <br /> North (or east limit: ~tJ51•k a~6L~. South (or west) limit: ~~'i~ G R~ <br /> in strict conforms ce with City of Eugene standard spec'Ifications for public Improvements (including current addenda), <br /> ;construction plans proved by the dty engineer or his representative, the current edition of "Procedures for Privately Engineered <br /> i Projects," the Eug ne City Code, and the standard and special conditions printed on this permit form. The owner/applicant is <br /> ~ responsible for p viding a copy of this permit to the contractor performing the work. <br /> i <br /> Contact Person ~G°~T~~~-- <br /> 395Se 1~t~c 'PeNpwl4~,- <br /> Signature Mailing Address <br /> Print signat e <br /> Date ~ Phone 3~ ~ 3 3 I City /State /Zip ~x-~VtS ~R `'~'7~ o <br /> DO NOT YYRnE BELOW THIS LNVE <br /> r ~ PUBLIC IMPROVEMENT PERMIT <br /> Permission is he by granted to applicant and applicants contractor to perform the work stated above, in conformance with <br /> ~i conditions listed ova, 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 /> .APPROVED: Date: <br /> City Engineer <br /> r <br /> i <br /> EIIQ: ~ VYhke: Owr»NDselpner Canary: CoMrecxor Pink Irapsator FEBRUARY 20(12 <br /> it <br /> <br />