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. <br /> City of Eugene <br /> Public Works <br /> <br /> Application for ublic Improvement Permit Engineering <br /> 858 Pearl Street <br /> Eugene, OR 97401 <br /> Job Number: (541) 682-5291 <br /> FAX: (541)682-5032 <br /> Contract No: <br /> I ~e F F (rrc s! ~ e hereby make application for a PUBLIC IMPROVEMENT PERMIT to <br /> (owner) <br /> construct public imp vements in the public way, as described below: <br /> Type of Improv ent: P^~t^~ T ~E`~' , W`~s~-F S•~arr•,w~•~~' S~'i ~tii,~s <br /> (paving, wastewater, storrnwater, street lights) <br /> Location: (j-r~ant L3s~h~I+2S svs~~vrslol~ <br /> (street or easement work is within or subdivision name) <br /> North (or east) I mit: South (or west) limit: <br /> in strict conforman with City of Eugene standard specifications for public improvements (including current addenda), <br /> construction plans a proved by the city engineeror his representative, the current edition of "Procedures for Privately Engineered <br /> Rrojects," the Euge City Code, and the standard and special conditions printed on this permit form. The owner/applicant is <br /> rf:sponsible for provi ing a copy of this permit to the contractor performing the work. <br /> ContactPers inn sc;~'~f I•^on~tlS - 3JZ~ q~tic~ <br /> Signature Mailing Address ~ Z~•Z- <br /> Printsignatu re ~ FF ti-rsane <br /> Date ! C ' Phone 1~_a <br /> ~ ~7i s - ll~ 13 City /State /Zip ?dS~J~ ~1 r~ ~ _ L/~ ~'t z ~ Z <br /> DO NOT WRITE BELOW THIS LINE <br /> PUBLIC IMPROVEMENT PERMIT <br /> Permission is here granted to applicant and applicant's contractor to perform the work stated above, in conformance with <br /> Conditions listed ab ve, 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 /> SPECIAL CONDITI NS <br /> APPROVED: Date: <br /> City Engineer <br /> I <br /> Eng: 604 FEBRUARY 2002 <br /> WhNe: Owner/Designer Canary: Contractor Pink: Inspector <br /> <br />