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Application for Public Improvement Permit <br />City of Eugene <br />Public Works <br />Engineering <br />Job Number. ~1 SI~7 <br />Contract No: <br />858 Peari Street <br />Eugene, OR 97401 <br />(541)682-5291 <br />FAX: (541)682-5032 <br />l~ lIJCOC.~q ~c.~Cl~ hereby make application for a PUBLIC IMPROVEMENT PERMIT to <br />(owned <br />construct public improvements in the public way, as described below: <br />Type of Improvement: U <br />Location: <br />North (or east) limit: <br />(paving, wastewater, stonnwater, street III <br />~/-~L <br />(street or t work Is within or subdivision name) <br />South (or west) limit: <br />in strict conformance with City of Eugene standard specifications for public improvements (including current addenda), <br />construction plans approved bythe 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 />~~ontact Person (prtn4 J~°I p C7~ls <br />'Signature ~ `~-" <br />print signature here ~~+ ~a-s ~- ~ c ><<~S <br />date G ~ 3° - ~~ Phone _~ -' / 9 ~-~-_ <br />Lc / S-lj-2266 <br />Mailing Address ~ 2 ~ ~- l~2~ ~c~ ~v{ <br />City /State /zip C ~y fn ~ ~ ~ 9 7~~ `~ <br />0o wo'r wrtrn: et:t~oxr THIS ut~ <br />-------------------------------------- <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 />condtions 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 />APPROVE <br />City Engin <br />Date: ~, ° Z/~~ <br />Enp: 604 FEBRUARY 20112 <br />WhMe: Orvnsdl)eslprMr Canary: Contractor Pink Inspector <br />