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<br /> A 1lcation for Public Im rovement Permit City of Eugene <br /> p P Public Works Engineering <br /> 858 Pearl Street <br /> Eugene, OR 97401 <br /> 541.682.5291 Phone <br /> Job Number j z Contract Number 541.682.5032 Fax <br /> ~ ~ (N - }7,tx(~ <br /> I, a hereby make application for a PUBLIC IMPROVEMENT PERMIT to construct public improvements <br /> (ow er) <br /> in th public way, as described below: <br /> Ty e of improvement:) ~ ~S~q~„ r~5-~~ <br /> (pawng, wastewater, stormwater, street li`g'hts) <br /> ~ p t <br /> Lo ation: l=•~S~' of kct.ulJ~~ g~L~C'~i ( E ~¢.S~}' d~ .o <br /> (Street or easement. work is wit in or subdivision name) <br /> N rth (or east limit: ~ ~ _ Z~,~ South (or~st) limit: ~ CN • ~ 1~ ~`{~c) ~ _ <br /> in str ct conformance wi~h City of Eugene standard specifications for public improvements (including current addenda), construction <br /> plan approved by the ci engineer or his representative, the current edition of "Procedures for Privately Engineered Projects," the <br /> Euge a City Code, and tfne standard and special conditions printed on this permit form. The owner/applicant is responsible for providing <br /> a co y of this permit to t~1e contractor performing the work. <br /> i <br /> Con act Person (print) Qfr~ Phone Number S d3 ~ ~ 3G ' ~ro7~ <br /> c/`~' <br /> SIGNATU <br /> ~'~'~a~ , Billing information: <br /> PRPrrsR7rATURESame ~ Different, see below <br /> t'v l9 0 7 <br /> DUTE r //'j S,. ~ h /rte <br /> 1 ~ ~ V _ ~ ~~s I ~.I • ~'1 NAME <br /> MAILING DDRE55 •1 <br /> ~e(/le( ~ ~ `S 81LLING A~DRE55 <br /> CITT / ST~.TE /ZIP <br /> ~ _ 3 y~_ g yy y CffY/STATE/ZJP <br /> PHONE NUMBER (business hours) <br /> PUBLIC IMPROVEMENT PERMIT <br /> Per fission is hereby gr nted to applicant and applicant's contractor to perform the work stated above, in conformance with conditions <br /> liste above, below, an on the reverse side of this permit form. <br /> The ermit shall be voi unless the work described herein is completed by: <br /> SPECIAL CONDITIONS <br /> APP OVED: DATE: Original to the City of Eugene <br /> city Enginee Copies to Owner, Co-owner, and Inspector <br /> <br />