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,1 <br />f <br />1 <br />. j, - <br />,j Public Works <br />.r: Appl~catran far Public lmpravement Permit , <br />1 Englneenng <br />. , City of Eugene , . . <br />Jfab, Nu:rr~~er~ Contract Number 99 E. Broadway~;;^~S~ite~406 <br />. Eugene, Oregon 914'4 <br />X541 } 682-5291 X541 } 682-5032 FAX <br />l~ hereby make application for a PUBLIC IMPRQVEMENT PERMIT to construct public improvements <br />(owner) . in the public way, as described below: <br />T e of fm rovement: ~ ~ to ~ ~ ~ ~ yp p ~ ~ ~11~ l'evrG~1, ~ , <br />(Paving, wasfewafer, sformwafer, street lights.) <br />Lacatlon. 4 . <br />` (Streef ar easemeraf pork is within or subdivision name) <br />~ ~ / f~ North far east} limit: ~ South or west limit: ~au~"~1 ~ ~ 4 ~ ~ <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 Gode, 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 />ac Person ~prlnt} ~ Phone Number <br />SIGNATURE Billing Infarrnation: <br />Same [ D~erent, see below PRINT SIGNATURE <br />DATA NA ~ <br /> <br />~ ~ ~ ~ MAILING ADDRESS ~ BILLING ADDRESS <br />. ~ n~ ~7~v3 ~ ~ 7b CITY I S ATE I ZI ~ CIT STA l SIP <br />PhIONE NUMBER ~b~siness hours <br />PUBLIC 1MPR~VEM~NT PERMIT <br />Permission is hereby granted to applicant's contractor to perform the work stated above, in conformance with conditions listed above, below, and an the reverse side of this permit form. <br />The permit shall be void unless the work described herein is completed by: <br />, r <br />SPECIAL ~o:~l~:rTl~»s~ . . , ~ . <br />~ i <br /> <br />APPROVED: DATE: Qnglna~ ~o ~h~! of Eugene, ; 1 City Engineer ~opes~o Qwne~r, ~a ~~ne,~, Inspector <br />F'.. <br /> <br />