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<; City of Eugene <br /> Public Works <br /> <br /> . 4pplication for Public Improvement Permit Engineering <br /> 858 Pearl Street <br /> Eugene, OR 97401 <br /> Jmb Number: (541) 682-5291 <br /> FAX: (541)682-5032 <br /> Cbntr~ct No: <br /> I,i r~Ctr1 ail ~./v ji ~ hereby make application for a PUBLIC IMPROVEMENT PERMIT to <br /> (owned <br /> c~nstruct public improvements in the public way, as described below: <br /> ~ /~T , `J/ 6C~- c,, <br /> Type of Improvement: <br /> (paving, wastewater, stonnwater, street lights) <br /> LOCatiDn. <br /> (street or easement work is within or subdivision name) <br /> I <br /> North (or east) limit: South (or west) limit: <br /> i~ strict conformance with City of Eugene standard spec'rfications for public improvements (including current addenda), <br /> construction plans approved by the city engineer or his representative, the current edition of "Procedures for Privately Engineered <br /> I~rojects," the Eugene City Code, and the standard and special conditions printed on this permit form. The owner/applicant is <br /> rresponsible for providing a copy of this permit to the contractor performing the work. <br /> ~ontact Person (prrr~ ~O V ~ r(`V ~ . <br /> ~4 F~aN S"~ S"~ <br /> >~ignature A Mailing Address - <br /> ~nnt signat re h re ~ ~ E' ~7 G <br /> bate C! - Pho ~ ~-City /State /Zip ~~~~-1 ~ ~ ~ ~ ~ ~ ~ 5 <br /> DO NOT WRRE BELOW T111S UNE <br /> PUBLIC IMPROVEMENT PERMIT <br /> Permission is hereby granted to applicant and applicant's contractor to perform the work stated above, in conformance with <br /> j conditions listed above, below, and on the reverse side of this permit form. <br /> The pemtft shall be void unless the work described herein is completed by: <br /> ;SPECIAL CONDITIONS <br /> i <br /> 'APPROVED: Date: <br /> i~ City Engineer <br /> Eng: 604 FEBRUARY 20t:YL <br /> White: Owner/Designer Canary: Contractor PMk: Inspector <br /> <br />