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-ti <br /> City of Eugene <br /> Public Works <br /> Application f r Public Improvement Permit Engineering <br /> Q 858 Pearl Street <br /> Job Number: 0 ~ Eugene, OR 97401 <br /> (541) 682-5291 <br /> FAX: (541) 682-5032 <br /> Contract No: <br /> I, A hereby make application for a PUBLIC IMPROVEMENT PERMIT to <br /> (ownert <br /> ,I construct public i provements in the public way, as described below: <br /> ~ 11 <br /> ~ Type of Impro ement: ~A~) rV Lt~~NA~>~'VyA)-t~-~ 5~1~21~/1tuQ~ ~~~,t~/ ~ 6N~'S <br /> (paving, wastewater, stortnwater, street lights) <br /> { Location: S <br /> ~ <br /> Q C7 1 U I S~ L'rJ <br /> { (street or easement work is within or subdivision name) <br /> II <br /> North (or east) limit: South (or west) limit: <br /> in strict conforman a 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 /> Projects," the Euge a City Code, and the standard and special conditions printed on this permit form. The owneNapplicant is <br /> responsible for prov ding a copy of this permit to the contractor performing the work. <br /> ' ~ ri~ ~A~~" - Cad 3 -7 <br /> Contact Person (prinQ <br /> S~gnature ~ ~ t Mailing Address / rK : ~ 4-' f wc' <br /> i. Print signature here ~ v? l ~ ~ - S <br /> ' Date Z • 3 _ ~ Ph ne 1 7U0 City f State ! Zip r . y ~ y~~ <br /> -~---ter-- <br /> l <br /> j DO NOT WRfTE BELOW THIS LINE <br /> PUBLIC IMPROVEMENT PERMIT <br /> jP+~rmission is hereby granted to applicant and applicant's contractor to perform the work stated above, in conformance with <br /> cconditions listed abov ,below, and on the reverse side of this permit form. <br /> ~h~E permit shall be v id unless the work described herein is completed by: <br /> ~P~ C1AL CONDITIO S <br /> A <br /> I <br /> aPf~ROVED: Date: <br /> ity Engineer <br /> ; <br /> <br /> Eng: 604 FEBRUARY 2t~ <br /> White: QwnedDesigner Canary: Contractor Pink: Inspector <br /> <br />