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Gity of Eugene <br /> Public Works <br /> . Application for Public Improvement Permit Engineering <br /> / I t,r/~,~ /858 Pearl Street <br /> • Job Number. ' . ~`j~~ ~ [ ~ t'/ ~ I/~ v Eugene, OR 97401 <br /> • ~ ~ ~ <br /> (541) 682-5291 <br /> Gontract No: ~ F .FAX: (541) 682-5032 <br /> 1, ~ e4'~' ~G~ 1~/1+~ ~ hereby make application for a PUBLIC IMPROVEMENT PERMIT toj <br /> construct public improvements in the.pub[ic way, as described below: • <br /> Type of Improvement: ~ ~ $ ~ $ U , <br /> (paving, wastewater, stonnwater, street Ifghts) <br /> i <br /> i <br /> j o t <br /> Location: ® ` + t^' ~I ~ ~..a~ <br /> .(street or easement work is within or subdivision name) <br /> 1~~ t p <br /> . North (or east) limit: -_1t~ A ~ t v?at ~ a y South (or west) limit: ~-U ~ ~J~ ~ d' $Gt%t~~' ~i ~~`+g <br /> r <br /> in strict conformance with City of Eugene- standard specifications for public improvements (including current addenda), <br /> ~ construction plans approvedbythecityengineerorhisrep~eserttative,thecurrente~ditionof`Procedures.forPrivatelyEngineered <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 /> i <br /> ~ Contact Person(p,;nn ~C~~c~dlkv', ~k', <br /> I ~ ~ <br /> Signature IVlailingAddress- a~~~ ~aG4q~at'{~y1 <br /> Print signature here t? SG~t rvb: f <br /> Date ~2°`/-CJ~ Phone~"'a? - City/.State /Zip~al+dna `~~~r <br /> II DO NOT WAnE BELAW THIS LINE <br /> ! ~ PUBLIC IMPROVEMENT PERMIT <br /> Permission is hereby granted to applicant and applicants wntractor 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 /> I <br /> APPROVED: Date: <br /> <br /> ~ City Engineer <br /> Eng: 60a ~ ~ FEBAUAAY Z0p2 <br /> • White; Owner/Des;gner ;Canary: Contractor Pink Inspector, <br /> <br />