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City of Eugene Public Works <br />Application for Public Improvement Permit Engineering <br />858 Pearl Street <br />Job Number: ~ Eugene, OR 974a~ ~54~ } 682-5291 <br />FAX: X541 } fi82-5032 Contract Nv: <br />l~ ' hereb make a lication for P ~ownery y pp a UBL1C IMPROVEMENT PERMIT to <br />construct public improvements in the public way, as described below: <br />T e of Im ravement: ~ yp P <br />(pa►+ing, wastewater, stormwater, street lights} <br />Location: <br />(street or easement work is within or subdivision name} <br />North or east limi#: ~ ~ ~ South ar west li ' ~ } ~ } m>t. <br />in strict cor~ormance with City of Eugene standard specifications for. public improvements including current addenda}, <br />construction plans approved by the cry engineer or his representative, the current edition of "Procedures for Privately Engineered <br />Projects,r the Eugene City Code, and the standard and special conditions printed on this permit form. The ownerlapplicant is <br />responsible for providing a copy of this permit to the contractor performing the work. <br />Contact Pers ~pri~ <br />Si nature ~l 9 Malling Address <br />Print si r h e ~ <br />Date p ~ ~ ~ hone CI I State 1 Z~ tY P <br />0o Nor w~ e~.ow n~is LINE <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 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 />~r~g: 6~4 FFBRUaRY 200 <br />White: dwnerlDeSigner .Canary: Contractor iainic; inspector <br />4 f z <br />f' <br />