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City of Eugene <br /> Publlc Works <br /> <br /> Application for public Improvement Permit Engineering <br /> 858 Pearl Street <br /> Job Number. Eugene, OR 97401 <br /> (541)682 5291 <br /> FAX: (541) 682-5032 <br /> Contract No: <br /> 1, hereby make appilcation for a PUBLIC IMPROVEMENT PERMIT to <br /> , <br /> constru public improvements in the pu is way, as described below: <br /> Type of Improve}nent: ~ I C t'l C ~ ~ ~I A,'t H <br /> II (paving, wastewater, atormwater, street IlQhts) <br /> coy?. Z- eo-r <br /> Location: 1~ I trl ~ 'R- ~'>(z. >J ~ ° "'C p`L' Pt 5 <br /> (street or easement work is wHhin or sut~divlsion name) <br /> North (or east) li~rtit: ~ ~ V L ~ ~ South (or west) limit: ~ ~ l3 ~ ~ <br /> in strict cortformanc~ with City of Eugene standard specifications for public improvements (including current addenda), <br /> construction plans ap~roved by the city engineer or his represerrtative, the current edition of "Procedures for Privately Engineered <br /> Projects,' the Eugene City Code, and the standard and special conditions printed on this permit form. The owner/applicant is <br /> reisponsible for provit~ing a copy of this permit to the contractor performing the work. <br /> Contact Person (Pr?nA.~ - h C~ 8 S o r~ I~• <br /> Signature Mailing Address i 5 t t5' Sv~l SFi Q V ~ to ISa <br /> Print signature here ! i x T,4Lot35 o rt <br /> Date 12 ~ 5 ~ n s Phone City /State / Zip ~ 1 V ~ ~ ~ b ~ Z 2 <br /> CS~~' (,8H-o~sZ <br /> oo rror wrurE et:ww TM~ urts <br /> - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - <br /> PUBLIC IMPROVEMENT PERMIT <br /> Permission is hereb granted to applicant and applicants contractor to perform the work stated above, in conformance with <br /> conditons listed abo e, below, and on the reverse side of this permit fore. <br /> The permit shall be void unless the work described herein is completed by: <br /> SPECIAL CONDITIONS <br /> I <br /> APPROVED: Date: <br /> City Engineer <br /> EnQ: 604 FEBI4UAHY 20Q2 <br /> While: OwnedDeeipner Canary: Contractor Pink: Inspector <br /> <br />