By signing, the undersigned certifies th a/she has read and understood the submittal airements outlined, and that he/she <br />understands that omission of any listed item may cause delay in processing the application. ' (We), the undersigned, <br />acknowledge that the information supplied in this application is complete and accurate to the best of my (our! knowledge. <br />PROPERTY OWNER OF TAX LOT: 'O0 <br />Name (print): Don Fulti& <br />A.ddres=_: 790 Lorane Hi&wsy Finail: <br />OR <br />Phone: '12-847-SIt3 Fait: <br />Date: l Ol i f 1 fr <br />PROPERTY OWNER OF TAX LOT: <br />Flame (print): <br />Address: <br />Email: <br />Phone' Fax: <br />Signature: Date: <br />PROPERTY OWNER OF TAX LOT: <br />Name (print) <br />Address: Email: <br />Cllr/Statelzip: Phone: Fax: <br />Date: <br />SURVEYOR: <br />Name (print): Renee Clough, PLS. PL-', .',ICI' <br />Company/Organization: Branch Engineering, Inc <br />Address: <br />City/State,2ip: Springheld,OR 9-;77 Phone 541-746 -063, fax: <br />E-mail: RateeCCbnnchengincering.com <br />Signature: Date: 101ifib <br />Planning & Development <br />Planning Division <br />99'A/. nY"AvenLe. E.rgme CA 9- 7401 <br />=horn. rdi 5-',:377 or <br />Updated: March 20-4 <br />?'cam 3 0, 5 <br />