sesiatly address the applicable approval criteria. <br />By signing, the undersigned certifies that h e/she has read and understood th ae : e submittal requirements <br />; eee that omission of any listed item may cause delay In processing the apiention: | War tec nde =u ay ee <br />at the information supplied In this application is complete and accurate to the best of my (our) ecowledse! Sas ares <br />OWNER (Also the Applicant? [iil] Yes / (_] No): <br />Stanley and Aer Hruby <br />Name (print): Arn pee Jo <br /> 28869 Gimpl ‘it Ret. <br />(541) 520-4909 <br />Phone: <br /> <br /> Address: <br />Eugene, OR 97402 <br />City/State/Zipy <br /> <br />Signature: <br /> <br />APPLICANT [_] / APPLICANT’S REPRESENTATIVE [_] (Check one): <br />Name (print): <br />Apne Fst a <br /> <br />Company/Organization: <br /> <br /> <br /> <br /> <br />Address: <br />City/State/Zip: E-mail (if applicable): <br />Phone: Fax: <br />Signature: <br /> <br /> <br />APPLICANT'S REPRESENTATIVE [Bl] / DESIGNATED CONTACT PERSON [Bl] (Check all that apply): <br />Zack P. Mittge <br /> Name (print): Hutchinson, Cox <br /> Company/Organization: <br />940 Willamette St., Ste 400 <br /> Address; Eugene, OR 97401 <br />City/State/Zip: (541) 686-9160 <br />Phone: <br />—————— <br />zmittge @ eugenelaw.com <br />E-mail (if applicable): <br />(541) 343-8693 <br /> <br />Fax; <br /> Signature: - <br />A ene-or.gov, in. nnn <br /> <br /> ~-99.W, 10™ Avenue <br />PProner: 541.682.5377 pee ant pla <br />Updated: January 2025 <br />Page 3 of 3