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s <br />€Ej f <br />Public Works <br />Application for Public Improvement Permit Engineering <br />. ~ y a ugene <br />Job Number Contrast Number. 99 E. Broadway, Site 400 <br />Eugene, Oregon 97401 X541 } 682-5291 <br />X541 } 682-5032 FAX <br />I, ~ hereb make a lication for a PUBLIC IMPRQVEMENT PERMIT to construct ublic im rovements Y pP p p fawner) <br />in the public way, as described below: <br />T e of Im rovement: ~ ~ ~ rr , ~ ~ ~ ~ YP p <br />~ ~ Paving, was#ewafer, sf wafer, streeflighfs. I~1 ~ ~ ~1 t~ ~ <br />/ E~ . Location: 3 <br />(Street ar easemenf wank is within ar subdivision name) <br />North or east hmlt: South or west limit: ! ~ } ~ } <br />in strict conformance with City of Eugene standard specifcations for public improvements including current addenda}, construction 3 plans approved by the city engineer or his representative, <br />the current edition of "Procedures far: Privately Engineered Projects," the <br />Eugene City Cade, and the standard and special conditions printed on this permit form. The, ownerlapplicant is responsible far <br />3 providing a copy of this permit to the contractor perrorming the work. <br />Contact Person riot ~ Phone Number ~p ~ <br />sl A uRE Billing Lnformation: <br />3 <br />. ~ S me ❑ Different, see below PRINT SI ATUR <br />~ k DAT NAME <br />MAILING ADDRESS BILLING ADDRESS <br />1 <br />CITY 1 ATE I ZIP CITY !STATE 1 ZIP <br />r . f <br />PHONE NUMBER ~buslness hours} <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 an the reverse side of this permit farm. <br />The permit shall be void unless the work described herein is completed by: . <br />SPECIAL CONDITIONS <br />APPROVED: DATE: Orrg~nal to the Cray of Eugene <br />. Cify Engineer Copies to owner, Go-0wner, and Inspector <br />FEB 2 3 2011 <br />