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Applicatioln for Public Improvelmeint Perlrnit <br />City of Eugene <br />Public Works <br />Engineering <br />Job Number: ~~~~ <br />858 Pearl Street <br />Eugene, OR 97401 <br />(541) 682-5291 <br />FAX: (541)682-5032 <br />Contract No: <br />h ~ ~~ ~ ' ~ ~ ~ hereby make lication foF a PUBLIC IMPROVEMENT PERMIT to <br />t~~- aPP <br />construct public improvements in the public way, as described below: <br />1~ ~. G i_ ~ <br />Type of Improvement: <br />(pavif~g, wastewater, storrnwater, street lights) <br />Location: ~ t~ f ~ ~it~~si IltiGt ,~v~iVi~f~~ <br />(street or easementwork is witnip or subdivision name) <br />North (or east) limit: <br />in strict conformance .with City of .Eugene. standard spec cations for public . improvem. enfs (including current addenda), <br />' constnacfion plans approved by the city engineer or his representative,the current edfion of "Procedures for Privately Engineered <br />Projects," the Eugene City Code, and the standard and special conditions printed on #his permit form. The owner/applicant is <br />responsible for providing a copy of this permit to the contractor performing the work. <br />Contact Person ~,r~q _ ' <br />I 2 t <br />Signature I Mailin Address ~ ~ ~`~ ~~ <br />9 <br />Print signature here h h r f'~ // ~. Q (~~ c,~,,M <br />Date Phone.: City/State/Zip ~;, ~~~._ V I (V~" <br />oo•NOrwRm: eslow rHls uNe <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 />The permit shati. be void unless the work described herein is completed by: <br />SPECIAL CONDITIONS <br />I. APPROVED: <br />South (or west) limit: <br />Date: <br />- ERg: 604: Fi='SRUARY 20ta2 <br />YJhita; Owner/Designer Canary: Contractor PiMc Inspector <br />_._ _ __ <br />__. <br />