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<br /> . <br /> City of Eugene <br /> Public Works <br /> Application f r 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, d ~ ~ hereby make application for a PUBLIC IMPROVEMENT PERMIT to <br /> (owner) <br /> construct public im rovements inpthe public way, as described below: <br /> Type of Impro ement: ` A V' 1 N fv hAS ~C. WJI ~ t~- <br /> (paving, wastewater, stormwateG street lights) <br /> Location: r7~vTN i= ~Z !`U <br /> (street or easement work is within or subdivision name) <br /> A ~ <br /> North {or east) limit: S~ TIC L~~ South (or west) limit: $J ~ TI1 h St`s tN l-~ <br /> A~~Z <br /> ~n strict conforman a with City of Eugene standard specifications for public improvements (including current addenda), <br /> onstruction plans proved by the city engineeror his representative, the current edition of "Procedures for Privately Engineered <br /> ~rojects," the Euge a City Code, and the standard and special conditions printed on this permit form. The owner/applicant is <br /> jesponsible for pro 'ding a copy of this permit to the contractor performing the work. <br /> ~ontact Person (pdn ~ <br /> ~ignature Mailing Address <br /> Print signatur ere <br /> Bate Phone City /State /Zip <br /> DO NOT WRITE BELOW THIS LINE <br /> PUBLIC IMPROVEMENT PERMIT <br /> Piermission 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 oid unless the work described herein is completed by: <br /> SbECIAL CONDITI NS <br /> I <br /> APPROVED: Date: <br /> City Engineer <br /> i <br /> Eny: 604 FEBRUARY 2002 <br /> White: Owner/Designer Canary: Contractor Pink: Inspector <br /> f <br /> <br />