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<br /> I x <br /> y <br /> 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, hereby make application for a PUBLIC IMPROVEMENT PERMIT to <br /> (owner) <br /> ~ cpnstruct public improvements in the public way, as described below: <br /> j Type of Improvement: ~ ~ J~'/~~ ~~~/~-1~ ~ ~ <br /> (paving, wastewater, storrnwater, street lights) <br /> i <br /> i <br /> R <br /> ~ Location: ~ <br /> ( et or easement work is within or subdivision name) <br /> North (or east) limit: South (or west) limit: ~ (1 " G{,> <br /> in strict conformance with City of Eugene standard specifications for public improvements (including current addenda), <br /> construction plans approved by the city engineer or 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 Person lv~+~A T r- <br /> Signature Mailing Address ~ Z-~S ~ ~-Eu t ~ ,J <br /> Print si n tur here , / <br /> Date Phone 3y~ L'Z-~ City /State /Zip~~ Cam` 1 ~ `i <br /> DO NOT WRITE BELOW TFIIS LINE <br /> PUBLIC IMPROVEMENT PERMIT <br /> ~ Permission is hereby granted to applicant and applicant's 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 /> i <br /> The permit shall be void unless the work described herein is completed by: <br /> I <br /> SPECIAL CONDITIONS <br /> II <br /> ~i <br /> APPROVED: Date: <br /> City Engineer <br /> Eng"~ 604 FEBRUARY 20A2 <br /> Whfte: OwnedDesigner Canary: Contractor Pink: Inspector <br /> <br />