Fillable PO Box 458 * Veneta, OR 97487 * (City of Veneta)

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PO Box 458 * Veneta, OR 97487 * (City of Veneta)

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File type: PDF

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S:\FORMS\Public Works\word - excel\Public Private Improvement Plan Submittal.doc
PO Box 458 * Veneta, OR 97487 * 541-935-2191 * 541-935-1838 * www.VenetaOregon.gov
Date Received: ________________ Associated Land Use Application File: _______________
Applicant’s
Representative:
Address:
Phone:
Contact Name:
Email:
Project Name:
Assessor’s Map & Tax Lot #:
Site Address:
TYPE OF WORK
Check appropriate box(s)
Submittal Materials: 3 hard copies 1 digital copy
Applicant/ Authorized Agent’s signature: ________________________
Print name: ________________ Date: _________
General Terms & Conditions:
The Applicant’s Contractor is solely responsible for conditions of the job site, including safety of all persons and property during performance of the
work, and after normal working hours until the Public Improvement is accepted by the City. Safety provisions shall conform with OSHA and all other
applicable regulatory agency requirements. Inspection of work by City staff does not include review or approval of the Contractor’s safety
measures.
Public/ Private Improvement Plan
Submittal
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PO Box 458 * Veneta, OR 97487 * (City of Veneta)

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Completed 17 July 2020

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