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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. I (We), the undersigned, <br />acknowledge that the information supplied in this application is complete and accurate to the best of my (our) knowledge. <br />PROPERTY OWNER OF TAX LOT7 1429 <br />Name (print): 3s ,E12 Aq,64 <br />Address: Email:~~°`~^ o- CQJ <br />City/State/Zip: Cue,,Aw A 5 7 -/O ~ Phone Fax: <br />Signature Date: <br />PROPERTY OWNER OF TAX LOT: <br />Name (print): <br />Address:Email: <br />City/State/Zip:Phone:Fax: <br />Signature:Date: <br />PROPERTY OWNER OF TAX LOT: <br />Name (print): <br />Address:Email: <br />City/State/Zip:Phone:Fax: <br />Signature:Date: <br />SURVEYOR: <br />Name (print): v11L) y, IzV s.- W <br />Company/Organization: S// to SSO C /i~T~~s <br />Address: 5 W 'f T// 4,24O <br />City/State/Zip: 012, Cl •7LIQl Phone: , f/ Fax: /t,//5;7 <br />E-mail: LID <br />Signature: Date: /LAP1 L Z7, Z01 <br />Planning & Development Updated: December 2016 <br />Planning Division <br />99 W. 10T" Avenue, Eugene, OR 97401 <br />Phone: 541.682.5377 or E-mail:eugeneplanning@ci.eugene.or.us Page 3 of 4September 10, 2018, Meeting - Item 2C