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_ City of Eugene <br />Job # GorttraCt #201 05' 99 E. Broadway, Suite 400 <br />Eugene, Oregon <br />97401 <br />(541)682-5291 <br />541 682 5032 FAX <br />I, 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: <br />(Paving, wastewater, stormwater, streetlights.) <br />Location: <br />North (or east) limit: <br />(Street or easement work is within or subdivision name) <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. <br />Contact Person (print) <br />OWNER's SIGNATURE <br />PRINT SIGNATURE <br />DATE <br />MAILING ADDRESS <br />CITY / STATE / ZIP <br />PHONE NUMBER (business hours) <br />Phone Number <br />Billing Information: <br />❑ Same ❑ Different, see below <br />NAME <br />BILLING ADDRESS <br />PUBLIC IMPROVEMENT PERMIT <br />STATE / ZIP <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:Original to the City e of Eugen <br />City Engineer _ Coptes to Owner Co owner, and Inspector <br />