Note: This is not a complete list of requirements. Additional information may be required after further review in order to <br />adequately address the applicable approval criteria. <br />Ely signing, the undersigned certifies that he/she has read and understood the submittal requirements outlined, and that he/she <br />understands that omission of any listed item may cause delay in processing the application. I (We), the undersigned, acknowledge <br />that the information supplied in this application is complete and accurate to the best of my (our) knowledge. <br />OWNER (A#so the Applicant? [] Yes / ❑ No): <br />Dame (print): jV_! tk: LLU U VA -UN ktyi- hone: ie(�"Z ' °f=Sr� - ce-too <br />Address: <br />City/State/ # "L IiC �rZ � 0Tci <br />Signature: <br />APPLICANT ❑ / APPLICANT'S REPRESENTATIVEy'(Check one): <br />Name (print): <br />Cam pany/Organization <br />Address: k\ALL 1j <br />City/State/Zip: , X-L cal <br />Phone: 6 0 T -A", S - �e$Sb <br />Signature: <br />E-mail (if applicable): A,v-V j , l t tr7 9. AUt,Uf_(A a CO, <br />Fax: <br />APPLICANT'S REPRESENTATIVE ❑ / DESIGNATED CONTACT PERSON ❑ (Check all that apply): <br />Name (print): <br />Company/Organization: <br />In <br />Address: 72O A/ 7 �' S 4 Y <br />City/State/Zip: 12-0 r VN is.', lZ r'1"?3 c� E-mail (if applicable):.__�5 a v►cyf-I L�3 cti Syr ��►�. W», <br />Phone: 5�-11 �'7� 7 - �i o� C7 n . - . 1.- - Fax: <br />4vww.eu ene-or ov lannin <br />Planning & Development Updated: January 202S <br />Planning Division <br />99 W. 107N Avenue Suite 290, Eugene, OR 97401 <br />Phone: 541.682.5377 or E-mail: pianning0eueene-or.Fov Page 3 of 3 <br />