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City of Eugene <br /> Public Works <br /> <br /> Application for Public Improvement Permit Engineering <br /> Y 858 Pearl Street <br /> Jbb Number. ~ L~ Eugene, OR 97401 <br /> (541)682-5291 <br /> FAX: (541) 682-5032 <br /> Contract No: <br /> l~ j <br /> ~U~ L-=% hereby make application for a PUBLIC IMPROVEMENT PERMIT to <br /> (oamer) <br /> construct public imp ements in the public wlay., as described below: <br /> P~ ~ t 1OlJ,~~~ft ~~2Jv~~v-i i. QZ -S~ ~I ~~S <br /> Type of Improv ment: t ~ ' - <br /> (paving, wastewater, stonnwater, street lights) <br /> s~~ L~~ <br /> Location: <br /> (street or easement work is within or subdvlsion name)r' <br /> North (or east) I mit: South or west) limit: »~e (I ~ ~ <br /> it1 strict conforman with City of Eugene standard spec'rfications for public improvements (including current addenda), <br /> cpnstruction plans proved bythe city engineeror his representative, the current edition of "Procedures for Privately Engineered <br /> ~rojects," the Euge City Code, and the standard and special conditions printed on this permit form. The owner/applicant is <br /> r sponsible for provi ing a copy of this permit to the contractor performing the work. <br /> Contact Person ~ S <br /> _ ~ S U~4~ ~ ~ LIB ~ <br /> Signature , Mailing Address <br /> Print signature h e #~~~E'-- `~r~' r5 ~7 i...~ ~ <br /> pate ~ ~'G Phone , ~ City /State /Zip ~ / <br /> DO NOT WRRE BELOW THIS LJNE <br /> PUBLIC IMPROVEMENT PERMIT <br /> ~errnission is hereb granted to applicant and applicants contractor to perform the work stated above, in conformance wfth <br /> ndibtxts listed ab e, below, and on the reverse side of this permit form. <br /> l~he permit shall be oid unless the work described herein is completed by: <br /> ~PECIAL CONDITI NS <br /> APPROVED: Date: <br /> City Engineer <br /> Eng: 604 FEBRUARY 204 <br /> White: OwnedDesipner Canary: Comractor Pink Inspector <br /> <br />