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REPRESENTATIVE (If different from Surveyor): <br />Name (print): <br />Company/Organization: <br />Address: <br />E-mail: <br />Signature: <br />Phone: Fax: <br />Date: <br />**Attached additional sheets if necessary. <br />Planning & Development <br />Planning Division <br />99 W. 10TM Avenue, Eugene, OR 97401 <br />Phone: 541.662.5377 or E-mail:eugeneplanning@cl.eugene.or.us <br />Updated: December 2016 <br />Page 4 of 4 <br />