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City of Eugene . Public'Works <br />Application for Public im rQvement Permit Engineering <br />p <br />858 Pearl Street <br />Job Number. ~ Eugene, DR 974D1 1541 } f~82-5291 <br />FAX: X541 } fi82-5032 <br />Contract No: <br />~ <br />l7 ~ ~ ~ hereb make a lication for a PUBLIC PR (owner} y PP IM ~VEMENT PERMYT to <br />construct public improvements in the public way, as described below: <br /> <br />Type of improvement: <br />. paving, wastewater, starmwater, street ~igh#s} <br />• ~ ~ Locatron. <br />r<street ar easement work is within ar subdivision name <br />I1~ for east} i~rn~t. South l~mrt. <br />in strict conformance with City of Eugene standard specifications far public improvements including current addenda, <br />construction plans approved by the 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 an this permit form. The ownerlapplicant is <br />responsible for providing a copy of this permit to the contractor performing the work. <br />Contact Person ~~ri~ <br />Signature Mailin Address ~ ~ 9 <br />Print signature e <br />Date ~ ~ " Phone C' 1 State ! Zi ~ ~ ~ ~Y P <br />0o Nor wRnE e~.aw nt~s uN>W <br />PUBLIC IMPROVEMENT PERMIT <br />Permission is hereby granted to applicant and applicant's contractor to perform the work stated above, in cvr~ormance with <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: <br />City Engineer <br />~~g: ~Q4 FEBRUARY 20Q2 White: 4wnerlDesigner Canary: Conxractor Pink: Inspector I <br />