HomeMy WebLinkAboutPermit Building 1983-2-11
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. APPLICANT:
MAILING ADDRESS:
CITY, STATE, ZIP:
LAND MANAGEMENT DIVISION
DePilrlmenl 01 Public Works
Loretta Ilacauley
4757 Jasper 'Road
. Springfield, OR 97473
---- BP 233-85,. i8-02-0S-l_3
/ 4200
RE: Temporary Mobile Home Permit Number:
Map/Tax Lot No. :
INFORMATION PROVIDED BY THE APPLICANT
1) Person with medical hardship L ~t'Ct.. lJ o.......d.v.e.&I'a6P
2) Person providing care 1-."1\' ~ /fA M,{q (J tI.._ulJ..4L(
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3) Famiiy relationship of the above " /lAIlI H ,-"P.../
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Resident of the principal dwelling l "Ie.. rfh
Resident of the temporary mobile home L lib
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6) Signatures:
Person with Medical Hardship
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Pets~n Providing Care /
Date:
Date:
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INFORMATION PROVIDED BY THE PHYSICIAN OR THERAPIST
1) Name of pat~ent
2) Nature of the medical hardship
3)
Does this hardship necessitate that a family member provide care?
Please comment: .
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Physician's Signat~re
Mailing Address:
Lane County Public Works / Land Management
Telephone:
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Division / 125 E.
687-4061 .
8th Ave., Eugene OR 97401
City, State, Zip:
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