By signing, the undersigned certifies that he/she has read and understood the submittal requirements <br />outlined, and that he/she understands that omission of any listed item may cause delay in processing the <br />application. I (We), the undersigned,acknowledge that the information supplied in this application is <br />complete and accurate to the best of my (our) knowledge. <br />x <br />OWNER (Also the Applicant? Yes / ❑ No): <br /> <br /> <br /> <br /> <br />APPLICANT / APPLICANT'S REPRESENTATIVE ❑ (Check one): <br /> <br /> <br /> <br /> <br />APPLICANT'S REPRESENTATIVE ❑ / DESIGNATED CONTACT PERSON ❑ (Check all that apply): <br />Name (print):Company/Organization: <br />Address: <br />Phone: <br />Signature: <br />City/State/Zip: <br />E-mail: <br />OREGON LICENSED SURVEYOR* (As required under EC 9.8210(1)): <br />*If surveyor has signed the site plans or tentative plat, signature below is not required. <br />Name (print): 1J1"tf V\ & Lt- f r " <br />Company/O^rganization:8tx5' "t' J`rt7Yt[� PLS#: (Z90-7q <br />y <br />Phone: c7 ®9-7 j 6 E-mail:. <br />Signature: <br />www. euoene-oc aov/olann, <br />Planning & Development Updated: March 2026 <br />Planning Division <br />99 W. 101" Avenue Suite 290, Eugene, OR 97401 " <br />Phone: 541.682.5377 or E-mail: planningaOeuaene-or.gov Page 6 of 6 <br />