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V ~ <br /> j City of Eugene <br /> Public Works <br /> A placation f r Public Improvement Permit Engineering <br /> 858 Pearl Street <br /> Job Number: T-~~~L3 ~ Eugene, OR 97401 <br /> (541) 682-5291 <br /> FAX: (541) 682-5032 <br /> Contract No: <br /> ~ /I,, <br /> I, ~ . !-f° . 1 hereby make application for a PUBLIC IMPROVEMENT PERMIT to <br /> (owner) <br /> construct public im rovements in the public way, as described below: <br /> Type of Impro ement: ~~V/N~- W~STft?~ i <br /> ~fL~ STj2,E£T G/,STS <br /> (paving, wastewater, stormwater, street lights) <br /> Location: ,~S 2I~ r D~r~aJJ <br /> (street or easement work is within or subdivision name) <br /> North (or east) limit: South (or west) limit: <br /> i~' strict conforman e with City of Eugene standard specifications for public improvements (including current addenda), <br /> onstruction plans a proved by the city engineer or his representative, the current edition of "Procedures for Privately Engineered <br /> rojects," the Euge a City Code, and the standard and special conditions printed on this permit form. The owner/applicant is <br /> sponsible for pro ding a copy of this permit to the contractor performing the work. <br /> ~ , <br /> ontactPerson~P~~ ~~N K-'~l'~/ 'Z~--'~(,Z ~Q~' S <br /> ignature ~ ~ -~'f'y~ Mailing Address ~Z~S -~eSS~-lu ~ ~`I <br /> rant signature here ~ t ~ a C- - t= I <br /> ate Phone '~l City /State /Zip ~ ' e v I'LL/ 7 `f C ~ <br /> DO NOT WRITE BELOW THIS LINE <br /> - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - <br /> PUBLIC IMPROVEMENT PERMIT <br /> P rmission is hereb granted to applicant and applicant's contractor to perform the work stated above, in conformance with <br /> c nditions listed abo e, below, and on the reverse side of this permit form. <br /> T e permit shall be oid unless the work described herein is completed by: <br /> S ECIAL CONDITI NS <br /> A PROVED: Date: <br /> City Engineer <br /> <br /> Eng: 804', , FEBRUARY 21702 <br /> White: Owner/Designer Canary: Contractor Pink: Inspector <br /> <br />