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Note: This is not a complete list of requirements. Additional information may be required after further review in order to adequately address the applicable approval criteria. 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? ❑I• Yes / ❑ No): Name (print): Terry & Deb Family Trust% Deb Stapp Phone: 541-514-1487 Full Address: 850__Waverly Street, Eugene, Oregon 97401-5232Pa Signature: i OWNER (Also the Applicant? ❑ Yes / ❑■ No): Name (print): Pamela SCOtt Phone• ` > Full Address 90 Waverly Street, Eugene, Oregon 7401 ` 3.2 Signatu APPLICANT ❑■ (if different from owners) Name (print): Donald Nickell company/organization: Nickell Land Surveying & Planning, LLC Full Address: 33225 Craig Loop, Cottage Grove, Oregon 97424 Phone: 541-968-2905 Signature: E-mail (if applicable): nickell2u@msn.com APPLICANT'S REPRESENTATIVE ❑■ / DESIGNATED CONTACT PERSON ❑ (Check all that apply): Name (print): Deb Stapp Company/Organization.- Full Address: 850 Waverly Street, Eugene, Oregon 97401-5232 Phone: 541-514-1487 E-mail (if applicable): d�� '. ` .r�Z��•,�, �c' �"l Signature: s, 4 V9` www.eu ene-or. ov tannin Planning & Development Updated: January 2026 Planning Division 99 W. 10" Avenue Suite 290, Eugene, OR 97401 Phone: 541.682.5377 or E-mail: planninp,@eugene-or.gov Page 4 of 5