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City of Eugene <br /> Publlc Works <br /> Engineering <br /> 4pplication for Public Improvement Permit <br /> 858 Pearl Street <br /> Job Number. Eugene, OR 97401 <br /> {541)682-5291 <br /> FAX: (541)682-5032 <br /> Contract No: <br /> 17~tZW-~C~O! E(.rt=[.IL. hereby make application for a PUBLIC IMPROVEMENT PERMIT to <br /> c~~ <br /> cohstnact public improvements in the public way, as described below: <br /> Type of Improvement: SAN t rl.t~, ~ ~'y-------~'~ V~C'~'!~~[~'2" k `'TU~M~~'Ti~2' <br /> (pavtrlg, wastewater, stormwater, street Ilghts) S~~T l-lC~ kfT S <br /> Location: ~R~c.[ t H-1 ~ t 1=t~E Lt~ pc. a-i <br /> (street or easement work is within or sub vision name) <br /> Northlimit: t~1C1fLTi~ tTF- pSaYrf~S'r. So~imit: laoYc.~ '~T . <br /> in strict conformancQ with City of Eugene standard specifications for public improvements (including current addenda), <br /> construction plans approved by the city engineeror his representative, the current edition of "Procedures for Privately Engineered <br /> Projects," ate Eugent3 City Code, and the standard and special conditions printed on this permit form. The owner/applicant is <br /> responsible for providing a copy of this permit to the contractor performing the work. <br /> Contact Person ~ D,~{ l ~ L4-~Aib 50 ?.1 <br /> Signature ' Mailing Address { t ~ n~ <br /> Print signat re h ' <br /> Date Phone toik0 City /State /Zip L1"t lJl.S ~ja Rp oQ.. a'1 IZc~ <br /> DO NOT WgITE BELOW THtB 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 /> conditions listed above, below, and on the reverse side of this permit form. <br /> '>t'he permit shall be Woid unless the work described herein is completed by: <br /> SPECIAL CONDITIONS <br /> APPROVED: Date: <br /> City Engineer <br /> <br /> Eep: gpq FEBRUARY 20Q2 <br /> While: Ovmedpesipner Canary: Conhactor Pink Inspector <br /> <br />