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www.eugene-or.gov/planning Planning & Development Updated: May 2024 Planning Division 99 W. 10TH Avenue Suite 290, Eugene, OR 97401 Phone: 541.682.5377 or E-mail: planning@eugene-or.gov Page 3 of 3 Note: This is not a complete list of requirements. Additional information may be required after further review in order to adequately address the applicable approval criteria. By signing, the undersigned certifies that he/she has read and understood the submittal requirements outlined, and that he/she understands that omission of any listed item may cause delay in processing the application. I (We), the undersigned, acknowledge that the information supplied in this application is complete and accurate to the best of my (our) knowledge. OWNER (Also the Applicant? Yes / No): Name (print): ____________________________________________ Phone: ___________________________________________ Address: ___________________________________________________________________________________________________ City/State/Zip: _______________________________________________________________________________________________ Signature: ___________________________________________________________________________________________________ APPLICANT / APPLICANT’S REPRESENTATIVE (Check one): Name (print): ________________________________________________________________________________________________ Company/Organization: _______________________________________________________________________________________ Address: ____________________________________________________________________________________________________ City/State/Zip: ___________________________________________ E-mail (if applicable): ________________________________ Phone: _________________________________________________ Fax: ______________________________________________ Signature: ___________________________________________________________________________________________________ APPLICANT’S REPRESENTATIVE / DESIGNATED CONTACT PERSON (Check all that apply): Name (print): ________________________________________________________________________________________________ Company/Organization: _______________________________________________________________________________________ Address: ____________________________________________________________________________________________________ City/State/Zip: ___________________________________________ E-mail (if applicable): ________________________________ Phone: _________________________________________________ Fax: ______________________________________________ Signature: ___________________________________________________________________________________________________ Ed St Clair 276 W 12th, LLC 541.514.3601 PO Box 51161 Eugene, OR 97405 Amy Raven Gotta Dance Trust 1885 W 15th Avenue Eugene, OR 97402 amyctharp@gmail.com 541-912-5657 carol schirmer Schirmer Consulting, LLC PO Box 10424 Eugene, OR 97440 schirmer@schirmerconsulting.com 541.234.5108