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City of Eugene <br /> Public Works <br /> Application for Public Improvement Permit Engineering ~ . <br /> w-a 858 Pearl Street, <br /> Job Number: ~ . Eugene, OR 97401 <br /> (541) 682-5291 <br /> FAX: (541) 682-5032 <br /> Contract No: <br /> h ~ Gd-~t~ ~ hereby make application for a PUBLIC IMPROVEMENT PERMIT to <br /> (owner) <br /> construct public improvements in the public way, as described below: <br /> y <br /> Type of Improvement: ~'S ~ ~ h2r,~w~ w ~,7,~,/'' -5 i ~,~j''I <br /> i <br /> (paving, wastewater, stonnwater, street lights) ~ e;~'-~ <br /> Location: ~'°t ~ ~i e_ ~ ~ ~t ~ v ~ S i m, . <br /> (street or easement work is within or subdivision name) ~ , <br /> North or east) limit: c=' ~ South (o west) imit: v" ' <br /> in strict conformance with City of Eugene standard specifications for public improvements (including current addenda), <br /> construction plans approved bythe 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 (v~nA ~ a ~ T`°-~ i S C'~ ~ ~ ~{,e}^ r <br /> <br /> ~ Signature. ~ Mailing Address. ~ ~~~e.-~ t°`P~ <br /> 1c Print signature here L 2 Y g kC K <br /> `Date _ Phone ~ ~S ' 3 ~ SS City /State /Zip _ ~ ~ ~ ~ <br /> !m NOT WRITE BELOW THIS LINE <br /> PUBLIC IMPROVEMENT PERMIT <br /> Permission is hereby granted to applicant and applicants contractor to perform the work stated above, in conformance wfth <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 /> APPROVED• _ Date: „~~G~~7 <br /> City Engineer <br /> Eng: 604 FEBRUARY 2002' <br /> White: OwnedDesigner Canary: Contractor Pink: Inspector <br /> <br />