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Utility Public Way Use <br />Permit Application <br />File with: Public Works Maintenance - 1820 Roosevelt Boulevard <br />City of Eugene <br />Public Works <br />Maintenance <br />1820 Roosevelt Boulevard <br />Eugene, OR 97402 <br />Phone: (541) 682 -4800 <br />Fax: (541) 682 -4882 <br />A. Job address JQQ _ ) \11 7s C1J_y! -1 1001) QA T / 9 W MAcy/WA -,C• <br />Subdivision Addition <br />Utility FSN Utilitytype OUBLIG pHOIJFS Job No. <br />Utility Address City Zip <br />Utility Contact Name � Utility Contact Phone `� �� 9 <br />S �� ��5 /O ^ � 2�.5 Address I Z RRE <br />Contractor name _F_/! LYI Phone - — <br />C i <br />City /State/Zlp �SG� r A� C.C.B. LIC. d License Expires <br />B. Description of proposed activity (Engineering plans for work must be attached) Y <br />b M c n 0,8U 4AU) <br />- ,�D_ul <br />Gib f l.�.Sbi ,4N y BEO 1) 1 L 1 , 4A h!Q �t w 1 �7] cQhrsPaE]'F��1 - <br />C. Work Activity within public way (48 hours before digging, call 1- 800-332 -2344 for utility locate) Project Specifics (required) <br />Surface: ;`( Concrete/asphalt CI Gravel C DirUgrass ❑ Landscaping Depth <br />Location. ❑ Street or alley ❑ Plant Strip X Sidewalk ❑ PUE ❑ Other _— Width <br />Method: 1 - 1 Open trench CJ Boring CI Aerial CI Pulling in existing conduit Length <br />❑ Other <br />D. Joint activity details (required to obtain joint trench permit fee): (check boxes)l <br />❑ PUE: <br />• Joint activity with (list of utilities) <br />• In street G In plant strip ❑ Under sidewalk ❑ Other JUN 0 8 20 <br />I =1 Joint trench notification (required II activity involves open trench more than 400' in length) <br />E. City trees In vicinity of proposed work O Yes )(No Show critical root zone on plans <br />R Sensitive area (check map) Cl Yes )< No If yes, apply for erosion permit <br />I that I have read and understand the conditions printed on bath sides of this a/ap o pni lfcoartion using or for doing work within the Duhlic way and further <br />G. As utility representative, state <br />the workluse permit being sought is for the purposes stated and no other, unless expressly reque ed o and authorized by a permit. I agree to indemnify and <br />state <br />hold the City of Eugene, it's officers, agents, and employees harmless from any injury or damage taus r ml 'ng to the activities specilied in this application. <br />p <br />X- Date '2.6- A9Phone <br />Name �y� f�j - JK Y✓.$K� Signature �'/ /��� -^� <br />(Print) r n As Utility Representative) <br />/�;. �,Qca/Ea P '9 e � E'tli1�,dR 9T 5 0 1 <br />Representative's Address _ <br />FOR OFFICE USE ONLY <br />Date <br />Permit approved by <br />CONDITIONS:' <br />❑ Traffic control plan required. Submit plan to Traffic Operations for revlew,and approval prior to commencing activity. <br />❑ No lane closure before 8:15 a.m. or after 4 p.m. <br />1-1 Use "Bike Lane Closed" sign If obstructlaning bikeways; provide acceptable bicycle route through the work zone. <br />Cl Use 'Sidewalk Closed" sign If abstructioning sidewalk; provide acceptable pedestrian route through the work zone. <br />CJ Coordinate Installation with City Engineering and/or developer to avoid construction conflicts. <br />❑ Erosion permit required. <br />❑ Work shall comply with current City tree protection standards and ANSI -Z -133 pruning standards. <br />• See continuation of conditions on back of form. EROSION PERMIT <br />APPROVED <br />tae <br />Additional Requirements: <br />1 �-�' Date Gl `�' BV DateAppflcabonRecelved —i� Ras— <br />LogNo. Login <br />WMITEIMM YELLOW/ APPLICANT XLrzwD <br />SLO-037 6190 <br />