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City of Eugene <br />99 E. Broadway, Suite 400 <br />Eugene, Oregon 97401 <br />(541) 682 -5291 <br />541) 682 -5032 FAX <br />t f P-XV t LL. LLG 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: P "W tt 1� w• AW mf V6t /5VwJA 1M f JYVAt& r <br />nn,, dd Jin eenn'',, ( wastewater, stormwater, street tights.) <br />Location: t"� �`'' �/ ��"� -A <br />(Street or easement work is within or subdivision name) <br />North (or east) limit: <br />South (or west) limit: <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 owner /applicant is responsible_ for <br />providing a copy of this permit to the contractor performing the work. 0..,1a ,1 <br />Contact Person (print) ��n"� 1 "�1K� Phone Number 7C►' T� �33z <br />OWNER's SIGNATURE N Billing Information: <br />mLAAK -N " UL- <br />PRINT SIGNATURE <br />�I col za�v <br />DATE <br />Q - y. i 01( (13 <br />MAILING ADDRESS <br />�U6�tik 111(L 4 1 14-4-6 <br />CITY / STATE / ZIP <br />�'�-' 33 3 <br />PHONE NUMBER (business hours) <br />9 same ❑ Different, see below <br />[ki I1.1 <br />BILLING ADDRESS <br />CITY / STATE / ZIP <br />PUBLIC IMPROVEMENT PERMIT <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: <br />City Engineer <br />DATE: Original to the City of Eugene <br />Copies to Owner, Co- owner, and Inspector <br />