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~ <br /> t . <br /> <br /> " ' City of Eugene - <br /> Public Works ; <br /> Application f r Public Improvement Permit Engineering <br /> j 858 Peari Street <br /> Job Number: ~ ~ [ G' Eugene, OR 97401 <br /> (541) 682-5291 <br /> FAX: (541)682-5032 <br /> Contra/c~t Na <br /> ' ~ 1, I ' hereby make application for a PUBLIC IMPROVEMENT PERMIT to <br /> (owner) <br /> construct public im rovements in the public way, as described below: <br /> Type of Impro ement: ~tI~ISTE[.,liFT~l2 ~TD2ri1/,JA-TE~~ <br /> (paving, wastewater, stormwater, street lights) <br /> Location: ~ c.~-? - ~1~.¢a2 <br /> (street or easement work is within or subdivision name) <br /> North (or east) imit: I~,j~' South (or west) limit: <br /> in strict conforman a with City of Eugene standard specifications for public improvements (including current addenda), <br /> Construction plans a proved by the city engineer or his representative, the current edition of "Procedures for Privately Engineered <br /> F~rojects," the Euge a City Code, and the standard and special conditions printed on this permit form. The owner/applicant is <br /> responsible for prov ding a copy of this permit t/o'the contractor performing the work. <br /> Contact Person (pr; ~j' <br /> ~ ~~~~~-d~/fir <br /> Signatur ~ Mailing Address <br /> Print signature here ~ r- <br /> Diate~ - Phon~ City 1 State !Zip / / 7 <br /> DO NOT WRITE BELOW THIS LINE <br /> PUBLIC IMPROVEMENT PERMIT <br /> Permission is hereb granted to applicant and applicant's contractor to perform the work stated above, in conformance with <br /> conditions listed abo e, below, and on the reverse side of this permit form. <br /> 'The permit shall be v id unless the work described herein is completed by: <br /> SF~ECiAL CONDITIO S <br /> APPROVED: Date: <br /> City Engineer <br /> Eng; 604 FEBRUARY 2002 <br /> White: OwnedDesipner Canary: Contractor Pink: Inspector <br /> <br />