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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 LOT: LCO <br />Name (print): Lt t- LA Wt <br />Address: 40,1 Email: <br />City/State/Zip: gut r"V Cri q-t4o( Phone: 5¢(.524-4ZWFax: <br />R11Q <br />Address: Email: <br />Phone: Fax: <br />Date: <br />PROPERTY OWNER OF TAX LOT: <br />Name (print): <br />Address: Email: <br />Phone: Fax: <br />Date: <br />SURVEYOR <br />Name (print): t-Ad"Aaxwu Dyk"s <br />Company/Organization: POA ,E- tsav I� V -re. u.rt <br />Address: P.o.ESo 25'Z--1 't -.11!'L o2. 'IRZ <br />4O <br />City/State/Zip: Phone: A-4'65-4Wax: 5{(-49S—%Z+ <br />E-mail: OMIc¢Sn V0At'IE-rJ€f" <br />Signature: ` . 0.1. Date: (o - cog ?,a (5 <br />Planning is Development Updated: December 2016 <br />Planning Division <br />99 W. 10TM Avenue, Eugene, OR 97401 <br />Phone: 541.682.5377 or E-mail:eugeneplanning@ci.eugene.or.us Page 3 of 4 <br />