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<br /> ~ ' <br /> <br /> ' City of Eugene <br /> Public Works <br /> piication f r Public Improvement Permit Engineering <br /> 858 Pearl Street <br /> ~ Job Number. .3 Eugene, OR 97401 <br /> f I (541) 682-5291 <br /> FAX: (541)682-5032 <br /> I i Contract No: <br /> I, D /50I') hereby make application for a PUBLIC IMPROVEMENT PERMIT to <br /> ~ (owner) <br /> ;construct public i provements in the public way, as described belo /w: /I <br /> j PGV~ n a ~PUxi1P~. S~rniu~W~°~: s~-r ~i 1'S. S TnPr~ T~cPS, <br /> Type of tmpr ement: <br /> (paving, wastewater, stormwater, street lights) <br /> s <br /> i <br /> Location: <br /> (street or easement work is within or sugdivision name) <br /> orth (or east limft: ~vQn /r~~a~~aw~ ~ ~~J~o' South (or est imit: ~Gr7~t-vc°S ~ `_~QrrSs ~vn <br /> i <br /> M <br /> ' in strict conforms ce with City of Eugene standard specrfications for public improvements (including current addenda), <br /> construction plans proved by the city engineeror his representative, the current edition of "Procedures for Privately Engineered <br /> Projects," the Eug ne City Code, and the standard and special conditions printed on this permit form. The owner/applicant is <br /> responsible for p viding a copy of this permit to the contractor performing the work. <br /> 3 <br /> 'Contact Person <br /> fir.. , S~ f <br /> j~ Signatur Mailing Address 1$ 7 2 w' l I <br /> Q m~ r <br /> I ~ Print signat re he °~~'~~'rs ° ~ Fu ~ t'.~? c, G l2 9 7y L> <br /> Date j Z ~ 6 S Phone ~K b - ~Z 2 7-~ City /State /Zip ~ <br /> ? I <br /> DO NOT WRRE BELOW THIS UNE <br /> PUBLIC IMPROVEMENT PERMIT <br /> Permission is he by granted to applicant and applicant's contractor to perform the work stated above, in conformance with <br /> conditions listed ova, below, and on the reverse side of this permit form. <br /> The permit shall b void unless the work described herein is completed by: <br /> (SPECIAL CONDI IONS <br /> j <br /> i <br /> { ;APPROVED: Date: <br /> City Engineer <br /> i <br /> 6ilg:604 FEBRUARY 20x2 <br /> White:Owner/Designer Canary: CorKrsdor Pink Inspector <br /> <br />