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www.eugene-or.gov/planning Planning & Development Updated: March 2026 Planning Division 99 W. 10TH Avenue Suite 290, Eugene, OR 97401 Phone: 541.682.5377 or E-mail: planning@eugene-or.gov Page 5 of 5 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:__________________________________________ Phone: ___________________________________ E-mail (if applicable): ___________________________________________ Signature: _________________________________________________________________________________________________ APPLICANT’S REPRESENTATIVE / DESIGNATED CONTACT PERSON (Check all that apply): Name (print): ____________________________________Company/Organization: __________________________________ Address: __________________________________________City/State/Zip:__________________________________________ Phone: _________________________________________ E-mail:___________________________________________ Signature: _________________________________________________________________________________________________ OREGON LICENSED SURVEYOR*(As required under EC 9.8193(1)): *If surveyor has signed the site plans or tentative plat, signature below is not required. Name (print): _____________________________________________________________________________________________ Company/Organization: ______________________________________________PLS #: _________________________ Phone: ___________________________________________ E-mail: ________________________________________ Signature: ________________________________________________________________________________________________ ____________________ ____________________ _______________________ _______________________ Ted Taylor 2020 McLean Blvd Eugene, OR 97405 Lloyd L Tolbert, LS Tolbert Associates, LLC P.O. Box 22603 Eugene, OR 97402 541-359-8426 lloyd@tolbertassociates.com Same as Representative Lloyd L Tolbert, LS Tolbert Associates, LLC 2813 541-359-8426 lloyd@tolbertassociates.com 541-953-7226