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City of Eugene Public Works A~ lication for Public Improvement Permit Engineering 858 Pearl Street ~ J b Number: ~ ~ / ~ Eugene, OR 97401 p (541) 682-5291 FAX: (541) 682-5032 Contract No: l ~~~QL~ hereby make application for a PUBLIC IMPROVEMENT PERMIT to (o r) 'construct public improvements in the public way, as described below: I~ ( A~~,~ Type of Improvement: a!~~-~=-~~,~ i ~tZ ~~-ict4,.IJ t C.~v~. (paving, wastewater, stormwater, street lights) II I i Location: ` (street or easement work is wlthln or subdlvlsion name) t ~5T ~A~ ~H ~ Z Nort (or east limit: i aC South r west limit: ~ fj~q-ti 1rl ~ Z ~ ~ in strict conformance with City of Eugene standard specifications for public improvements (including current addenda), construction plans approved by the city engineer or his representative, the current edition of "Procedures for Privately Engineered F~rojects," the Eugene City Code, and the standard and special conditions printed on this permit form. The owner/applicant is responsible for providing a copy of this permit to the contractor performing the work. Contact Person (p~nn CAA-~'DL L ~f-J L fr~ h J +~I11rr" l~ ~ Mailing Address ~-`~-3--~JJ ~4 ~ ~ ~r~ ~ ~ Signature Print si na re re ~E ~ pate ~ D ~ ~ Phone ~ ~ L ~ City /State /Zip c~ 'L ~ 74~C) ` DO NOT WRITE BELOW THIS LINE PUBLIC IMPROVEMENT PERMIT permission is hereby granted to applicant and applicant's contractor to perform the work stated above, in conformance with Conditions listed above, below, and on the reverse side of this permit form. ~'he permit shall be void unless the work described herein is completed by: SPECIAL CONDITIONS 1APPROVED: Date: City Engineer Enp: 804 FEBRUARY 2oQ2 Whfle: OwnedDeslgner Canary. Contractor Pink Inspector .,-~.r~,