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, <br /> f <br /> City of Eugene <br /> Public Works <br /> Application for Public Improvement Permit Engineering <br /> j,,/ p 858 Pearl Street <br /> Job Number. / / Q Eugene, OR 97401 <br /> (541)682-5291 <br /> FAX: (541)682-5032 <br /> Cointract No: <br /> +~IGtx~2{ lJtzut~~t°• 1 <br /> ru5 ~'r°e. <br /> j, ,Stri bblPw MErn~ ~ ~r-u~S~' # y hereby make application for a PUBLIC IMPROVEMENT PERMIT to <br /> c~~ <br /> iconstruct public improvements in the public way, as described below: <br /> Type of Improvement: l ~ ~ ~ t h€t.t, t t-?Cti _ <br /> (paving, wastewater, stormwater, street lights) <br /> j <br /> 1 ~ Location: G€{.LTiZkt- $i,~lD Q.-'6t9'[TIt-~C~ ~1'•~Tt"i`IO?1. Pl~+""' ~c9~L SU21 P,~c~4_ <br /> ~ (street a easement work is within tx sub vision name) ~.~UOYI.I `r"'~-V`~T <br /> Z'tS~ `~V <br /> t14 CfF -C?'~'~- ~"~5~ '.-o~.~"tt-F ~ '1'sE~,. <br /> North (~~aet) limit: t~T~2h~Tto µ ~ South (a~~nrest) limit: tt-~TE2'S~C-+ IOI~? OF <br /> Z~~ ~ ~*~.M-~ i~-~e~_. Z~vv~' G~,+-c.T2ht.. 6~.~D . <br /> in strict conformance with City of Eugene standard specifications for public improvemerrts (including current addenda), <br /> construction plans approved by the city engineer or his representative, the current edition of "Procedures for Privately Engineered <br /> P~ojects' the Eugene City Code, and the standard and special conditions printed on this permit forth. The owner/applicant is <br /> responsible for providing a Dopy of this permit to the contractor performing the work. <br /> Contact Person (prrnq <br /> T~S12e- Mailing Address ~r~'tit u~b ~Su:t-~e 2 i O <br /> S~gnatu <br /> print si n tt~re here ~et l~D~~ i ANC <br /> s~iro'7 Sy l 13y5-y31a c' i state i zi ~tcget,e , aR ~l,~t~~ <br /> ' Date Phone dy p <br /> DO NOT WRITE BELOW THIS UNE <br /> PUBLIC IMPROVEMENT PERMIT <br /> F~ertnission is hereby granted to applicant and applicants contractor to perform the work stated above, in conformance with <br /> dondltions listed above, below, and on the reverse side of this permit form. <br /> the permit shall be void unless the work described herein is completed by: <br /> SPECIAL CONDITIONS <br /> APPROVED: Date: <br /> City Engineer <br /> <br /> F_qp: 604 >~ruaar ~ <br /> White: OwnedDesipner Canary: Comractor Pink Inspector <br /> <br />