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i <br /> I <br /> I <br /> i <br /> E <br /> fc <br /> I <br /> . City of Eu ene <br /> g <br /> . ~ Publlc Works <br /> App~~catia~ far Pub~~c ~m raveme~t P~rm~t Engineering <br /> <br /> 3 <br /> 858 Pearl Street <br /> ~1 ~ E <br /> Job Number. ugene, OR 9?4a1 <br /> X541 } 882-5291 <br /> <br /> 3 <br /> <br /> 3 <br /> FAx: ~5~~} ss2-5a~2 <br /> Contract No: <br /> I, hereby make application for a PUBLIC iMPRQVEMENT PERMIT to <br /> <br /> ~ (owner} <br /> construct public improvements in the public way, as described below: <br /> Type of Improvement: ~ <br /> paving, wastewater, stormwater, street iigi~ts} <br /> Location: ~ <br /> tstree# or easement work is wititin or su~divisian name} <br /> f <br /> North for east} limit: rya ~U ' ~ ~f~~Z/ South for west} limit: ~~v a~ <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 uPracedures for Privately Engineered <br /> Projects," the Eugene City Code, and the standard and special conditions printed an this permit form. The ownerlapplicant is <br /> responsible for providing a copy of this permit to the contractor performing the work. <br /> J ~ <br /> Contact Person ~ ~ ~ ~ ~ ~ J' ~ <br /> . <br /> Si nature - , llllailin Address ~ ~ . ~ ~ <br /> g 9 <br /> Print signatu a here ~ ~ ~ . ~ ~ <br /> Date I ~ ~ Phone ~ Ci 1 State 1 ~i ~ ~ <br /> tY P ~ <br /> Q4 Nt7T WRri'E BELOW THIS ttNE <br /> ~................r....,. ,...........~.,.._...r........,...~ ,..r ............,......~....~..,......~..w, <br /> PuB~~C ~MPRa~rEM~NT PERMIT <br /> Permission is hereby granted tv applicant and applicant's contractor tv perform the work stated above, in can#vrmance with <br /> conditions listed above, below, and an the reverse side of this pem~it form. <br /> The permit shall be void unless the work described herein is completed by: <br /> SPECIAL CONDITIONS _ <br /> APPROVED: Date; <br /> City Engineer <br /> ~~g: ~~4 FEBRUARY 2QQ~ <br /> While: pwr~erlCesigner Canary: Cantraotor Flnlc Inspector <br /> <br />