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i <br /> Application for public Improvement Permit _ city of Eugene <br /> Public Works Engineering <br /> <br /> - 858 Pearl Street <br /> ! Eugene, OR 97401 <br /> 541.682.5291 Phone <br /> Job Number , d Contract Number 541.682.5032 Fax <br /> I, hereby make application for a PUBLIC IMPROVEMENT PERMIT to construct public improvements <br /> (o ner) <br /> in t e public way, as de cribed below: <br /> T pe of improvemen : ~ y~~~~- ,~~~T~~AT~~ ~~~/~~j~~~'' L/GyT~ <br /> (paving, wastewater~s~t'orimwater~st/reetlights) ? <br /> L cation: j/y/L~ ~`~C/7/Y~ ~~7/ ~/~/C~ ~~~C~i~.s <br /> (Street or easement. work is within or subdivision name) 4/s~jf~ L~~~ ~~/f'~'y <br /> orth (or east) limit: South (or west) limit: <br /> in s riot conformance w th City of Eugene standard specifications for public improvements (including current addenda), construction <br /> pla s approved by the ity engineer or his representative, the current edition of "Procedures for Privately Engineered Projects," the <br /> Eu ene City Code, and he standard and special conditions printed on this permit form. The owner/applicant is responsible for providing <br /> a c py of this permit to he contractor performing the work. <br /> C ntact Person (print) av Phone Number (sy/, _ /GO 1 <br /> ' /ya <br /> $IGNA RE <br /> Billing information: <br /> ~ {iµ? <br /> PRINT GNATURE Same ~ Different, see below <br /> ~ /5 - Z0~7 CCC444"' <br /> DATE <br /> NAME <br /> MAILI ADDRESS <br /> BILLING ADDRESS <br /> CITY / TATS i <br /> CITV /STATE /ZIP <br /> Yr 7y ~ <br /> PHON N BER lhusiness hounl <br /> PUBLIC IMPROVEMENT PERMIT <br /> Pe mission is hereby g anted to applicant and applicant's contractor to perform the work stated above, in conformance with conditions <br /> lis ed above, below, a d on the reverse side of this permit form. <br /> Th permit shall be voi unless the work described herein is completed by: <br /> SPECIAL CONDITIONS <br /> 1 <br /> A PROVED: DATE: Original to the City of Eugene <br /> Copies to Owner, Co-owner, and Inspector <br /> City Engine r <br /> <br />