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r <br /> City of Eugene <br /> Public Works <br /> <br /> Application for Public Improvement Permit Engineering <br /> 858 Pearl Street <br /> J¢b Number: Eugene, OR 97401 <br /> (541) 682-5291 <br /> FAX: (541)682-5032 <br /> ntract No: <br /> HACSA) <br /> I, ereby make application for a PUBLIC IMPROVEMENT PERMIT to= <br /> (owner) <br /> c nstruct public imp vements in the public way, as described below: y 1 <br /> Type of Improv ment: I-GZV IY1G WQS~-eWa#~'~., ~t-ormWA~~ 1 re~~` L1G~'1~T`J <br /> (paving, wastewater, stonnwater, street lights) <br /> Location: <br /> (street or easement work is within or subdivision name) <br /> North (or east) I mit: H A t ~'O?r1 ~ Yom. South (or west) limit: ~ an ~ ~ G~e-~" AVE. <br /> i strict conforman with City of Eugene standard spec'rfications for public improvemerrts (including current addenda), <br /> c nstruction plans proved by the 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 prov' ing a copy of this permit to the contractor performing the work. <br /> 7 <br /> ontact Perso ~n<i I -1 <br /> ignatu MailingAddress~l~ 4.~V ~~lAno R~ <br /> rint sign ure ere ~U Q ~ <br /> ate 1 Phone , oR 2 ' ~~3~ City /State /Zip <br /> DO NOT WRITE BELOW THIS LINE <br /> PUBLIC IMPROVEMENT PERMIT <br /> ermission is here granted to applicant and applicants contractor to perform the work stated above, in conformance with <br /> nditions listed ab ve, below, and on the reverse side of this permit form. <br /> he permit shall be oid unless the work described herein is completed by: <br /> PECIAL CONDITI NS <br /> PPROVED: Date: <br /> City Engineer <br /> Eng: 6b4 FEBRUARY 2002 <br /> White: Owner/Designer Canary: Contractor Pink Inspector <br /> <br />