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City of Eugene <br /> Public Works <br /> Application for Public Improvement Permit Engineering <br /> 858 Pearl Street <br /> Job Number. S ~ Eugene, OR 97401 <br /> (541) 682-5291 <br /> FAX: (541)682-5032 <br /> Contract No: <br /> I,I hereby make application for a PUBLIC IMPROVEMENT PERMIT to <br /> I E (owner) <br /> c~nstruct public imp ements in the public way, as described below: <br /> E <br /> Type of Improv ment: ~ ~ ~ <br /> (paving, wastewater, stomtwater, street lights) <br /> 3 <br /> 1 <br /> ~ Location: ~v S ~ n~iG / ~ •`L ~ ~ ~S ~ /~`~GG-i d`ZV S T O --y p <br /> ~ (street or easement work is wNhin or subdvision name) <br /> i <br /> North (or east) li it: South (or west) limit: <br /> i irj strict conforman w~h City of Eugene standard specffications for public improvements (including current addenda), <br /> j construction plans roved by the city engineer or his representative, the current edition of "Procedures for Privately Engineered <br /> Plrojects," the Euge City Code, and the standard and special conditions printed on this permit form. The owner/applicant is <br /> responsible for provi ing a copy o~f-tAhis permit to the contractor performing the work. <br /> <br /> ` Oontact Person (p~inq ~ { AJ <br /> Signature Mailing Address 3g~ WG`~~~~ ~'1 <br /> Print signature here ~ ` t t' .q vv~ YLt. c ad <br /> Date D--l7- Phone y~~ <br /> ' o ~ ~3 City /State /Zip Lam' ~ 7~ 01 <br /> DO NOT WRRE BELOW THIS LINE <br /> PUBLIC IMPROVEMENT PERMIT <br /> ~rmission is hereb granted to applicant and applicant's contractor to perform the work stated above, in conformance with <br /> nditions listed abo e, below, and on the reverse side of this permit form. <br /> The permit shall be id unless the work described herein is completed by: <br /> i <br /> SPECIAL CONDITI NS <br /> i <br /> APPROVED: Date: <br /> City Engineer <br /> ~I <br /> Enp:'f# FEBRUARY 20(12 <br /> White: OwnedDsalpner Canary: Contr~tOf Pink IMpeCMr <br /> <br />