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I, J-#?AklrL. 60CA ft " hereby make application for a PUBLIC IMPROVEMENT PERMIT to construct public improvements <br />(owner) <br />in the public way, as described below: <br />Type of Improvement: !Ll <br />(Paving, wastewater, stormwater, streetlights.) <br />Location: e- t \4 \&4 �T . <br />(Street or easement work Is within orsubdivislon name) <br />North (or east) limit: 1°x.63 ° °"' South (or west) limit: 0 M O V 41 TIIL <br />in strict conformance with City of Eugene standard specifications for public improvements (including current addenda), construction <br />plans approved by the city engineer or his representative, the current edition of "Procedures for Privately Engineered Projects," the <br />Eugene City Code, and the standard and special conditions printed on this permit form. The ownerlapplicant is responsible for <br />providing a copy of this permit to the contractor performing the work. <br />Contact Person (print) ® ( f4' <br />OWN R's SIGNATURE <br />PRINT SIGNATURE <br />� � <br />DATE <br />Phone Number <br />Billing Information: <br />.Same ❑ Different, see below <br />b c s 10 5 • <br />MAILING ADDRESS <br />NAME <br />BILLING ADDRESS <br />Permission is hereby granted to applicant's contractor to perform the work stated above, in conformance with conditions listed <br />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 />APPROVED: DATE: Orrgrnal to fhe City of Eugene <br />City Engineer Copres to Owner,,Co owner, antllnspector. ` <br />City of Eugene <br />Job # `� Contract #201:... -05 99 E. Broadway, Suite 400 <br />Eugene, Oregon 97401 <br />(541) 682 -5291 <br />(541) 682 5032 FAX <br />