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www.eugene-or.gov/planning Planning & Development Updated: May 2025 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 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: ___________________________________________________________________________________________________ Rolland R Korinek 541-968-1504 2644 Hawkins Ln Eugene, OR 97405 Lloyd L Tolbert, LS Tolbert Associates, LLC P.O. Box 22603 Eugene, OR 97405 lloyd@tolberetassociates.com 541-359-8426 Same as Representative