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C'Ity of Eugene <br /> Public Works <br /> Application for Public Improvement Permit Engineering <br /> L 858 Pearl Street <br /> Job Number: ~ ~ ~ Eugene, OR 97401 <br /> (541)682-5291 <br /> FAX: (541) 682-5032 <br /> Contract No: <br /> I, --a~~ <br /> L'~Di~1 D. hereby make application for a PUBLIC IMPROVEMENT PERMIT to <br /> (owner) <br /> construct public improvements in the public way, as described below: <br /> Type of Improvement: ~Z" ~ 1 <br /> (paving, wastewater, stormweter, street lights} ~5 <br /> Location: Lit,G_~ <br /> 11,"`-'~- JU Qj.~~(i t,~r.1 '~~t LO ~ ~T~--~ <br /> (street or easement work is within or subcdvislon name) <br /> North (or east) limit: South (or west) limit: <br /> in strict conformance with City of Eugene standard spec'rfications for public improvements (including current addenda), <br /> construction plans approved by the city engineeror his representative, 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 /> responsible for providing a copy of this permit to the contractor performing the work. <br /> Contact P c>~~4 Q ~ <br /> Signature Mailing Address ~ ~ y ~~-S F4~ <br /> Print si ure here <br /> Qate Phone ~-Q ~7 ~7 City /State /Zip <br /> DO NOT WRrTE BELOW THIS LINE <br /> PUBLIC IMPROVEMENT PERMIT <br /> Permission is hereby granted to applicant and applicants contractor to perform the work stated above, in conformance with <br /> conditions listed above, 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 CONDITIONS <br /> APPROVED: Date: <br /> City Engineer <br /> <br /> E11Q: 604 FEBRUARY 2042 <br /> White: OwnedDesiyner Canary: Contractor Pink Irrepector <br /> <br />