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a <br /> <br /> ' - <br /> i City of Eugene <br /> Public Works <br /> A plication for Public Improvement Permit Engineering <br /> 858 Pearl Street <br /> i <br /> Jpb Number: Eugene, OR 97401 <br /> (541) 682-5291 <br /> FAX: (54t) 682-5032 <br /> gontract No: <br /> I' <br /> I,I o wt~ L ~2 hereby make application for a PUBLIC IMPROVEMENT PERMIT to <br /> (owner) <br /> construct public imp ovements in the public way, as described below: <br /> Type of Improv ment: -PAyINC,, I+11A5~u~P~T12-, S-r~~rvt~+.~A~-E~. S~~-t~ t,a`tkzS <br /> f (paving, wastewater, stormwater, street lights) <br /> Location: ?R 3Erzu.Y Svt3ptvlsto,.~ <br /> (street or easement work is within or sutxliNsion name) <br /> North (or 'mit: yuD o ~ U~~A"! South (or es limit: GAKwA-ti <br /> in strict conforman a with City of Eugene standard specifications for public improvements (including current addenda), <br /> gonstruction plans a proved by the city engineer or his representative, the current edition of "Procedures for Privately Engineered <br /> i projects," the Euge a City Code, and the standard and special conditions printed on this permit form. The owner/applicant is <br /> responsible for prov ding a copy of this permit to the contractor performing the work. <br /> contact Person tp~r 'Tc»~ UII,~LT7E'R <br /> ~ p <br /> Signature Mailing Address ~63 ~V~ ~.kt,~~ ~O <br /> f~rint signat re ere a <br /> tats ~ Phone ` "6~S City /State /Zip ~ QR q~ ~C <br /> DO NOT WRITE BELOW THIS LINE <br /> { PUBLIC IMPROVEMENT PERMIT <br /> ermission is here y granted to applicant and applicant's contractor to perform the work stated above, in conformance with <br /> onditions listed ab ve, below, and on the reverse side of this permit form. <br /> The permit shall be void unless the work described herein is completed by: <br /> >SPECIAL CONDITI NS <br /> i <br /> ~4PPROVED: Date: <br /> City Engineer <br /> I <br /> Enp: 804 FEBRUARY 2002 <br /> White: Owner/Designer Canary: Contractor Pink: Inspector <br /> <br />