By 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. 1(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 (Also the Applicant? ❑ Yes / ❑ No): <br />Name (print): 6_5'E& 7'�� c / X a iS; 'cPhone: <br />Address: ,3 ©C A Y- <br />City/State/Zip: _ <br />��«�S'r I- Cr <br />711C <br />� <br />Signature: <br />GJKi` �T <br />�Zr> <br />BSc t, .� <br />APPLICANT ® / APPLICANT'S REPRESENTATIVE ❑ (Check one): <br />Name (print): A4"? M !`I <br />Company/Organization: le— " ` `c�Iy�c�- - <br />Address: 3 c o E Jf �� /_.. ` A k- c, <br />Cit State Zi � c ^ C7%Z cZ 7 Y <br />Y/ / p� •� E-mail (if applicable): <br />5'el / — G G� _ C, <br />Phone; Fax: � ` ' Z <br />Signature: _ <br />APPLICANT'S REPRESENTATIVE ❑ / DESIGNATED CONTACT PERSON M (Check all that apply): <br />Name (print): l� l- ��1 / 1� C (:: L2'j%�e� <br />Company/Organization: <br />Address: r�✓ L� �'iU1.1` `A�. <br />City/State/Zip: AQ.j� P.- E-mail (if applicable): wed kwyly4-At ."_t_ Tt c';;1 , <br />Phone: �� .{ ` % Fax: C° �:, q�_ �dj WA <br />E <br />Signature: <br />_�M& <br />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 />_._. vV2 W.ei.,ac,�fne_c,r.c�o�l.�rrarr; rrr;s <br />Planning & Development Updated May 2024 <br />Planning Division <br />99 W. 10T" Avenue Suite 290, Eugene, OR 97401 <br />Phone: 541.682.5377 or E-mail: �) 'Ll rtin ,Lci- ne_Or.go Page 2 of 2 <br />