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. <br />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. | {We), the undersigned, acknowledge that the Information supplied In this application Is complete and accurate to the best of my (our) knowledge. . <br />OWNER (Also the Applicant? [ill] Yes / ] No): <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />Dean and Belize Blachly (503) 267-6855 Name (print): Phone: 1455 Holly Ave. <br />Address: <br />Eugene, OR 97408 City/State/Zip: <br />we 2 a rane Lh yt? n-7 .: <br />Signature: Pe aon Ee a Cee hee ea <br />¢ coe Y a wo <br />APPLICANT 0 / APPLICANT'S REPRESENTATIVE oO (Check one): <br />Name (print): <br />Company/Organization: <br />Address: <br />City/State/Zip: E-mail (if applicable): <br />Phone: Fax: <br />Signature: <br /> <br />APPLICANT'S REPRESENTATIVE [lll] / DESIGNATED CONTACT PERSON [ill] (Check all that apply): <br />Zack P, Mittge <br />Name (print): <br /> Hutchinson, Cox <br /> <br /> <br /> <br /> <br /> <br />Company/Organization: <br />940 Willamette St., Ste 400 <br />Address: ‘ Eugene, OR 97401 zmitige @eugenelaw.com <br />City/State/Zip: E-mail (if applicable): <br />(541) 686-9160 (541) 343-8693 <br />Phone: Fax: <br />Signature: <br />www.eugene-or.9ov/planning eel <br />Updated: January 2025 <br />Planning & Development <br />Planning Division <br />99 W. 10™ Avenue Suite 290, Eugene, OR 97401 pace 3 of 3 <br />Phone: 541.682.5377 or E-mail: planning@eugene-or.eov age 30