HomeMy WebLinkAboutPermit Building 1989-8-10
.. RESIDf.NTlAL"
. APPLICA11fJ/PERMIT
225 North 5th Street
SpringfieZd. Oregon 97477
BuiZding Division
726-3753
fml(jjfl UL
1.-/&~ La.t..th1L- S'(-,Lt)- Phone: 747- Lel51
r;r{t!L Zip: 17L/77
-.
Job Location:
VIRfj /...d.ufu.-
I }()3-Z- 7--/0
ABoe800~3 ~p '"
SubdiJJision:
(l.mel":
Address:
City:
SPRINGFIELD
~
9-YLfA-'
Ta:: Lot #
() 1150-3
Rcce:.pt ,if
l40~l--
v
..
UJII3
.~lb,
.~.
Describo rl'ork:
~.~,~'21-
~ tJ-rJd 1.- ljpSeY5 - f (')1~ Ju1
D~ / ~ gq
QNmJ
~ddition
n
n
Remodel
Nobile Homo
Date of Application
Cont.ractors
General
i Plumbing
I Hechanical
I E~~ctrical
I Superv1"9inl\
1J6'l'~
~
',Lise. II
- ) ;/n I
'y,\! UV
l k. 0'
If)
IV
'61
Siqr.ed:
Data:
Exoires
Bldrs Board Re;r.
~ddr"ss
ha->~~ '
/'}a/~
E~eetr !cian
It is tho responDibility of t~ permit hoLder" to see that alL inspections are made at the proper tim~, tr.at Qcch ~88D is roadabZe
from'tM etreet, and that the permit aazod ie located at the front of the property.
4Bui!.ding D";ui:ior. app:rol..'sd plan B.hall. remain on tha auildin!? Sit~ at all times.
PROCEDlJRE FOR INSPECTION RSQUEST:CALL 726-3769 (rccoroel") state your City designated job numbel", job address, type o[ in3poc:~iclI
l"squestcd ar.d w.l:en you r.n:U be ready [or inspection, Contractors 01" G\Jnsrs ncme and phono numbcr. Requcsts rBceit:Bd be[crs 7.. 00 (:':'l
l.o.>ill bB mads thl: BamB day, l"SquBstS made a[ta' 7:00 (UIJ L1ill ba made the ncrt :.x>rki71.] day.
, rour City DBoigr.atod Job l/wlIber Io: 9' q 0 7/9
Reouil"ed TnsDp.ctionn
O SITE INSPECTION: To b. mad. after
excatlation, but prior to set up 'o[
[orms.
D UNDERSLAB PLUMBING. ELECTRICAL ~
: MECHANICA~: To bo mado boforo any
work is ':01Jerod.
FOOT ING ~ FOUNDA T ION: To be made
after trenches are excatlated and
[orms aro srectsd, but prior to
pouring cencret.;.
UNDERGROUND PLUMBING. SEW!.W. W,1TE,q.
DRAINAGE: To be made prior to fH-
Ur.g trencMs.
D, UNDERFWDR PLU/.mING ~ MECHANICAL'
, To bs mads prior to inotaLlatt.on of
floor insulation or decking.
r-i:l POST AND BEAM: To bB made prior to
~ installation of floor insulation 01'
decki"!! .
r;/\ RO/JGII PLtmBI/JG.n:r,ECTRICAL.A MECH-
L..L::::f ANICAL: No work is to be cotlered .
,ur.tiL thess trwpections havo beor.
mads and approue.:!. '
O FIREPLACE: P'rWr to placir.g facing
materials and befol"s framing inspec-
tion.
o
D
m
F~}fINC: MUst be l"squeoted aftsl"
approva.L of rough plwrbing, alectl"i-
cal & mechanical. Azz. roofing
bracing ~ chimncys, etc. must bs
:' conrpLstad. No wl"k is to be con-
, csaled until this inspection has
'be~~ made and approved.
riA INSULATION/VAPOR BARRIER IHSPECTION,
LL:J To be mads after all insul.:ltion ar.d
'. roquired IXlpOI" barl"iers are in place
, but before any lath, gypsum board or
wll. covering is applied, and befol'B
. ~y iMDulation is concealed.
rTA DRYWALL INSPECTION: To be made
LCJ after aLL drywLl is in place,
but prior to any taping.
D MASONRY: Steel location, boiuI
beams, grouting Ol" tlorticals in
accordancB with U.B.C. Section
2415.
O WOODSTOVE: After installation is
ccmplsted.
o
CURB & APPROACH APRON: After' forms
are orected bu.t prior to pouring
concrete.
DEUOLITION OR /.:OVED BUILDlliCS
~ Sani tary sezJel' ::appsd :It P~OpCl'ty lir.o
=:=J Sop tic tank ~~cd and fillD~ with ~l"Q~el
I Pinal - When abotle items are completed
~ and when demolition is oomplets 01' Btl'U~-
ture moved and prlmfisoB cleaned up.
I/olobi lo Homos
=:J Blocking and Set-up
=:J Plumbi"fl connoctionB -- scwer and IJa :sr
~ Electrical Cannoction - Blocking, sot-up
~ and plumbing connoctiono mr~st be appl"oved
before l'6questing elea:rical inspec:io~
=:J AccosS'OI":i Building
I Final - Aftar p3l"CneS, okil'ting, docks.
~ etc. are complet&d.
o
',ALL Pl"ojsct conditions, such as the installation of stroot tl"eBS, co~lotion of t~g
roquil"ad landscapir.g, etc., must be satisfied before the BUIWINC FINAL can bo raquoot3d.
o FIliAL PLUMBING
o FINAL MECIIANICAL
[K] FINAL ELECTRICAL
o
o
SIDEWALK & DRIVEWAY: For all con-
crete paving within stl"ect l'ight-
of-way~ to be made after all exca-
vating complete & form work & sub~
, bcIS~ matel"ial ,in place.
o
FINAL BUILDING: Tho Final Building Inspe'ction must be.rsqu.Botsd alter tha Final PZumbin.:;
,Electrical, and Noehar.ical Inspectiona hQ;vo been mads and approvj,d.
O !'ENCE: flJlon COl11pl~te -- Provide
gatos or .'IlOtlable ssctions through
P.U.E. '
o
,-
~ALL MANHOLES AND CLEANOUTS MUST BE ACCESSIBLE, AlJ.TUST!fENT TO DE WIDE AT NO COST TO C1':'Y I Page! of 2
I JOB NO.
I Zona: 1;1')12..
Lot Sq. Ftg.
I Df lot Cauel'ag;:
,f of StiJriee
TotaL Height
Topography
I
I TTEJof
Uai~1
GcrrrGp.
Carner t
Accessorii
I~//i'i?~ /~
I TOTAL VAW!:
I cvac.UGJ
S.D.C. 1.5",
'!JuUding Pormit
Stat. SW'charqe
Total. Cll1lrges
lITEM
I FixtlU'6S
I R.eidential II bath)
I Sanit..-u'y SeLJlll'
I Water
I
Plwnbing Pend t
Stat6 SU1'cr.a~e
Total Chnrg08
IITEJof
I Ren. So. fto.
I NBlJ/E:I:tend Circui to
I Temporary Service
Electrical Permit
State Surd1lll'oe
Total Char-ces
I ITEM
I Furnace ETU' S
I Exhaus t llood.
I Vent Fan
I Jl:Jodatoue
Permit I3Buanca
Mechanical l'el'mit
Stato Sw'cha1'Q~
SOLAR AjifESS
OccuooncII Gr<,.~
WT TYP!:
Interior
Cornel'
Panhandle
cut-de-sac
SQ.FTG
Valu. I
I
I
1
1
17352 --I
1 1
I I,
x
NO.
0> ~ :;<:::> 1
?J.~I
7/.731.
I
FEE
CIIARGE
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1
1
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NO. F!:E I
Z4Jl?~EI
I 1 ',I
1 I 'I
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I /-0'1
I zJ. -631,
NO. FEE I
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'2?~S:=>i
I
1
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CIIARGI:
CIIARGE
Total Charaes
-- !:NCROACHMENT --
Ise~~rit~ Davooit
I Storage
I Maintena~R
I Parmi t
Total ChaMee
Curbcu~
Sid_lk
FCrl:::c
I Electrical Lc.bal ~
I Mobi le Home
I
I
I TOTIIL AMOl/NT DUE:"
I
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%".76
REQ.-
L-COG""
]
II
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.
TYDB/Cor.st:
BfldrOomS:
I Enerrfll Sources
I lieat
I Water Y~atp~
I I Rmlg~
'I I Fireplace
wooa~tOl:8
II
Tlll"'e
I Dot Faces -
I
I P.L.
Nortll
lEast
ISou th
IWeet
Setbacks
lIou.se' Garage
Access.
Faes
Building Value & Permit
This permit ia granted on the ezpreos condition that th6 8~id conotruction
8halL~ in all respects, conform to the Ordinance adopted by the City of
Springfield, including the Zoning Crdinance, regutatiltg the cellstruotten
and use of buildings, and may be ;8uopended or reuoked at c':y time upon tltC-
lation of any prolJtswns of said.OrdinanC6S.
I Plan Cheek Fee: 1-/ J-/. 8" 3
ICatc Pai.d: (( - i- 04
IR.cdpt #: }'It1Z.:3;5
I Signed: flN jjiIJ/U1
Plumbing Permit
No person shall construct, install, alter or change any M'lJ cr e=iotin(}
plumbing or drainage oystem in whole or in part, untROD such person io the
legal po88e880~ of a valid plumber's license, except that a person may do
plumbing ,work to property which is owned, leaDed or operated by the appli-
cant.
Electrica I Perm it
Where State Law requires that the electrical work be done by an Electrical
Contractor, the electrical portion of this pennit shaU roOt be valid until
the Label has been signed by the Electrical Contractor.
Mechanical Permit
I
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I IIAVE CARI:FULLY !:XAMIN!:D the campl.ted application for permit, and do
hereby certify that all. information hereon is true and correct, an.:i I
further certify that any ar.d an lJOrk perfor:ned 8htllt be done in accor-
dance .nth the Ordinancee of the City of Springfield, and th. La-~. of the
State of Oregon pertaining to the work describod here::n, and that NO OCCU-
PANCY will b9 m::Jde of any structura Lritlur.At pBmriosion of tho Building Di-
vision. I {urthar certify that cmly.contractors and s:npz.,YBCB who arB in
oompliance with ORS 701.055 will bB used on this project
I) J 1;, ~---
Sign3d
g', /o~ %9
, I
/Jat.
{?PGI<.
~ <J...s-'
tit " ~ FOR OFFICE USE ONLY
L~~ coun,;ty AuthorIzatIOn for: APPlicatio,,// ~t?.5
Lr'E~/J/);C:- ~~/..I-I'I~</)/./}r-7/mO::fPerm't # . "{/7~
I SECT~?: II TAX /~:5 I
! LOT/PARCE~ [BLOCK I
:;(/ZRE~ mtY.e.,/<9 ~eer- ,e.~C;~/h::-.:L-r:---zLJ CJ4ctta.R)
FtJ6LL"Tn ~PROpr;; ffllA/: F ,f't-I-F/J <; "
D l';'jSTO~-L?u;; ~~ /1/ L~~4 )r-A2r~ / .);2
//77?-:F r?/l /~~ /?>>/..*/-/ .<'///~4r-4~
DSr?g-~RK~~ECey~~'? ";)q/r/~zn? I DEClAREO$VALUE
. OF BEDRootr~ J' ON//iL '1 # A/;;~L--:0 WATER SUPPLY o/Ei-C @:~~~~~~~~
7>>;7#22'5 ~ /~r- 2/65 / d#~4 1~~JYJ!4-/
~;/d~/# J~4L;b~/-2~~' O~Ebc:7/d I r~6-
,?"~#mr~ADDRE~4YE- ./ 9/~;:7;;? I~~G
.~
"'''''SHIP 12 I RANGE ?J3
S0BDIVISI~/~ARTITION {if appiicable)
PROpOSED USE OF PROPERTY
~eSidential 0 Industrial
o Commercial 0 Public.
I HAVE CAREFULLY EXAMINED THE COMPLETED APPLICATION ~'OR PERMIT, and uo hcre1.>y certify t.hat all information hereon is true and correct, and that I
have the following legal interel>t in the property,Oowner of record; OCQntrar.;tpllrcha~er;Oauthori:z;ed agent, '__: . ,'.'_ .~ .. -,~.. "..~-'>aQ.l.
I f:.:.rther certify that aiy and all work performed l>hall be done in accotdancF.: wi th the Ordinances of Lane County and the Laws of the State of Oregon
pertaining to the work doscribed herein, and that NO OCCUPANCY will be !:lade of any strllcture without the permission of the Building Division. I furw
ther certify that registration with the Builder's Board is in full force and effect. as required by ORS 701.055, that if 'exempt the basis for exemption
is noted hereon, and that only subcontractors and employees who are in compliance with ORS 701.055 will be used on this project. I HAVE READ AND
CHECKED THIS APPLICATION THOROUGHLY.
Do IV A. "p fYl /-'t.~ E
NAME (please print)
tlJ~?-,
/~.
SIGNATURE ---..
t,- gs
DATE
Partition #0
Parcel #0
I
CONDITIONS! W' ..
Parcel Size ,
.
rear
READ THIS SECTION CAREFULLY.
~PLANNING/ZONING: Zon.
Minimum Setbacks: CL, front
COMNENTS: dJ7t?
YOUR AUTHORIZATION ~AS
efJ-
BEEN BASED ON THE FOLLOWING
c~, side
interior
~r~~
~'
~
~f)
V
Dat.,k-2-~~B(' ~ rKl
Installation Record Issued? tj Yes 0 No
Maximum Depth
of Trenches
o SANITATION:
S. 1. It
B. P. It
. Installation
Specifications:
Gallon
Tank
Lineal Feet
of Drainfie1d
COMHENTS:
X Date:
PLANS EXAMINATION: Type - Group Us. ~ \?CO /=
COM>IENTS,CAlL ~R 1?F.:Cf, uIRE"!:J //J,<:PheTJO,(J~_
n
Date:
{<l-2.G..- ~ --dlP1
1
J="E5"5' DuE'Z..?. '3'2.. P/lol~-E 0 - '"2G - ~
PERMIT APPROVED BY BUILDING OFFICIAL/DESIGNEE leer ORS 456.805(1)) DATE
LANE COUNTY DEPARTMENT OF PUBLIC WORKS LAND MANAGEMENT DIVISION, 687-4061,
125 EAST 8TH AVENUE, EUGENE. OREGON 97401
SEE REVERSE FOR INSPECTION INFORMATION C14-25R~
.
.
SETB,\CKS A:-JD OTHER CO:mITIO:$ OF APPRO'I,'L ~lUST BE STRICTLY OBSERVEO. VIOLATION CAN RESULT'IN REVQ-
C,;71m1 OF 'I'lllS PERNI'i', CIT,WlO:J U~DSR PROVISIONS DE' LASE "COU::!Y' J INFRACTION ORDI:;A:;CE ,AND/OR OTHER.
REMEDIES ALLOWED BY LAW.
IoOHEN READY FOR INspeCTION, CALL 687-4065. A l-lINH1U:'l OF ,),T Lr.:AST 24 !lOURS AOVA:;::::E NOTICE FOR INSPEC-
1'IU:-I Rt:QL:t:STS ;.lLiST Ill:: Gl\:E:':. Have the following infon':tation ready: permit -number, job address, type
of inspection, when it will be ready, your name and phO~0 number, and any s?ccial directions to site.
BUILDING DIVISION:
REQUIRED l~SPECTIONS:
1.
Foundation Inspection: To be made after trenches are excavated and forms erected and when all
rnaterlalS to!:" the toundation are delivered on the job. t'lhere concrete from a central mixing
plant (commonly ~ermed "tr~~sit mixed") is, to be used, materialS. n.eed not be on the job.
Concrete ~ ~ Under-rloor Inspection: To be made after all in-slab or under-floor building
serV1~e e~uipment, conauit, piping accessor1es, and other ancillary equipment items are in
place but before any concrete is poured or floor she~thing,installed, including .the subfloor.
;raminq & Insulation Insoections: To be made after the roof, all framing, fire blocking, and
racing are 1n place ana all p1pes, fireplaces, chimneys, and vents are complete and all rough
electrical and plumbing. are approved.- All wall insulation and vapor barrier are ,in place.
2.
3.
'-
Lath and/or Gvpsum Board Insyection: To be made after all lathing and gypsum board, ',nterior
ana-exterlOr, 1S 1n-pTiCe OUt cetore any plastering is applied and before gypsum board joints
and fasteners are taped and finished.
5. Final Insoection: To be made after the building is complete and before occupancy.
APPROVAL REQUIRED. ~o work shall be done on any part of the building or structure beyond the point
indicated in each successive inspection without first obtaining the approval of the building official.
Such approval shall be given only after an inspection shall have been made of each successive step
in the construction as indicated by each of the inspections required.
NOTE: All building permits require inspections for the work authorized, such as but not limited to:
A. Block Wall: To be made after reinforcing is in place, but before any grout is poured. This
InSpection is required for each bond beam pour. There will be no approval until the plumbing
and electrical inspections have been made and approved.
___.~.__,__...........". B...~.5tove: To be made after completion of masonry (if applicable) and when installation is
complete. Installation shall be in accordance with an approved, nationally recognized testing
agency an? the manufacturer's installation instructions.
C. Mobile Home: An inspection is required after the mobile home is connected to an approved
sewer or-5eptic system for setback requirements, blocking, footing connection, tiedowns,
skirting, and plumbing connections.
1. Footings and piers to comply with State foundation requirements for mobile homes or as
reconunendcd by the man~facturer. \
2. Mobile home minimum finish floorele~ation 'sha(l'be certified when required by a flood-\~
plain management: letter.
J. Mobile home tiedowns, when required, and. skirting shall be installed and ready for inspec-
tion within at least 30 days after occupancy, Tiedowns and skirting shall b~ installed
per enclosure.
D. Sw!mm!n9 Pool. Below grade when steel is in place and before concrete is poured. Above grade
When pool-rs-1nstalled.
APPROVED PLANS }\UST BE ON THE JOB SITE AT ALL TIMES DURING WORKING HOURS. THIS PERMIT' WILL EXPIRE
IF WORK DOES NOT BEGIN WITHIN 180 DAYS, OR IF WORK IS SUSPENDED OR ABANDONED FOR MORE THAN 180 DAYS.
SUSPENSION OR REVOCATION t1AY OCCUR IF THIS PERMIT WAS ISSUED ON THE BASIS OF INCOMPLETE OR ERRONEOUS
INFORMATION.
ANYONE PROCEEDING PAST THE P/?IllT or REQUIRED INSPECTIONS WILL DO SO AT TIlEIR OWN RISK.
l
SUBSURFACE: AND ALTERNATIVE: SEWAGE DISPOSAL ~: ,
1. Permits shall be effective for'one year from the date of issuance.
2. Upon completing the construction for which. a permit has been issued, the permit holder shall
notify the Lane County Department of Planning and community Development by submitting the
installation record form. The Department shall inspect the construction to determine if it
complies with the rules contained in this division. If the construction does comply with such
rules, the Department shall issue a certificate of satisfactory completion to the permit; holder.
If the construction does not comply with such rules, the Department shall notify the permit
holder and shall require satisfactory completion before issuing the certificate. Failure to
meet the requirements for satisfactory completion within a reasonable time constitutes a vio-
lation of ORS 454.605 to 454.745 and this rule.
Setbackn
Subsurface
Sewaqe Disposal
Septic Tank
10'
10'
5'
50'
. ..,
Drainfield
10'
10'
10 '
100'
F:-o:n:
Interipr property lines
Edge of road riqht-of-way
Building foundation
.Wells. other ","'ater sources
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.
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. APPLICANT LEE, DONALD.
TL~ 1703271001503 SUBDIV
NEW BLDG TYPE USE R BDRMS 0 UNItS ~01 STORl6S
. OWNER NME LEE, DONALD ADDr~
.- -CODE APPL NO ACTION DESCRIPTION SQ FT UNIT COST VALUATIDN
Bf"
.BP
BF' '
BF'
.BP
.
LANE COUNTY DEPT ENV MGT RECEIPT
" ADDR 2163 LAUR ST.,
I ,166085 "DATE 062785
SPRINGFIELD, OI~EGON .
LOT BLI<
tBLDGS 001 PHONE 747 6751
.
DAY~~.O!
.
FEE
.
'i I ~n
F"L 0 FIXTURES:
.MECH
. SUR
PCK
.BP LC 166085 SUPP
" PCI<
, ' SUR
.BP
SWR: FT, WTR:
. MECHANICAL FEE
STATE SUF~CHARGE
PLAN CHECI< FEE
FT. RAIN:
FT,
.
4'/
"
651.
28.00
18, ;!.0
1..'2
'-25, ()0
.
m
.
CATG:
.SEQU:
DOIAKEN
.
AF'F'
o .
I{Y RLH
RA
FP
SDS SI
PCK
OTH
ISS
o
TOTAL FEEH
.
.
ESlT,.
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COMPLETI ON DATE
22..32 CK
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a-
TRSjTAXLOT
OWNER
APPLICANT
(IF DIFFERi:iil)
JOB ADDRESS
VALUATION .
Ljo8 ~~~::O
. . . . . .
.
ADDRESS
rlUUKt))
REVISED
[ ] Addition
[ ] Correcti on
/C'o32. .co Bldg.
r Invest/
Db 1 Fee
REVISIONS CALCULATED BY:
DATE:
"28, COco
Mech.
, Plmb.
Fi xtures
, SWR FT
HTR FT
, RAIN FT
PCK
Surcharge
19.""2.0
I . 1.fi..
Sidewalk
Fldpln
SDS
DEQ
Other
TOTAL 47 - S 2.
.LrY.
~....?c.- l!3~-
.
APPLICATION # /~G.,C3 -~
PHONE'
PHONE'
PRIOR [ ] Refund
["1 Dep. On Iy [<}-I\mt. Due
"2.5"..;:. 0
(AMT. PAID)
7Zd;
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: ,e ", ," . e
.-.~ .' ":; LANE COUNTY DEPT ENV MGT RECEIPT ~'166085 DATE 062585
'.' APPLICANT "LEE{ DONALD ,ADDR 2163L.AURA ST., SPRINGFIELD, OREGON .
TU" 1 70~71 001503 SUBDIV LOT. BLK
NEW BLDO TYP~ USE R BDRMS 0 UNITS 001 STORIES OBLDGS 001 PHONE 747 67511tU
, ' .
. OWNER NME L:EE, DONALD ADDR 2163LAURA ST., SPRINGFIELD, OREGON ..
CODE APPL. NO ACTION DESCRIPTION SQ FT 'UNIT COST VALUATION FE~ DAYS
.BF' ' ,
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.I~P , ~'" < '.
BP , )
I u IYP,
-:: \ . FIXTURES, swe, FLF/WIR' FL RAIN: (/, FP)/ [', ·
.MECH MECHANICAL FEE ,,'t' \U'.
"'-/\ \ ,A\ '\ '
SUR STATE SURCHAF(GE 41. ":1, ,V, r'-' 'un",
PCK" PLAN CHECI( FEE 6~51. u
.m:' LC 1 6608~> F(AL 2~), 00 .
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I H C'ATC :
ttSEQU:
TAKEN
.
API"
1.
B-YRLH
RA
FP
SDS
SI
PCK
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OTH
IS'S
3
TOTAL FEE**
25l~.0.
~.
'~" "
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,EST~ COMPLETION ~ATE
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ACTIVI~ INFORMATION S~ET
~
COMPLETE THIS SECTION. INCOMPLETE FORMS WILL BE REJECTED!
: 1 1) 0 f{ .4 f... 0 1'7 A;;-/f?"
PERSON MAKING REQUEST
tJI6:5J.,AuRA. ~{',
MAILING ADDRESS
<.,PA~li G F I;'[I-D off, 97'-171
CITY STATE ZIP CODE
Vo VI! A hOlt( /"k/"j/
PROPERTY OWNER
~/ G 3 J. A. (j f/ A $7:-
MAILING ADDRESS
~ P p, '" ~ F 1 }=.- J. 0 (} 1 J 9 '7 Y ~ /
CITY STATE ZIP CODE
7q.? t$ 7>'; ~ ';?4 7 t i' 5'1
BUSINESS TELEPHONE # HOME TELEPHONE # BUSINESS TELEPHDNE,# HOME TELEPHONE #
2 PROPERTY ADDRESS [) I ~.3 )../4,. u R A (J: ~ p A tl. C; FI/<:-/.,O () 11
(IF DIFFERENT FROM MAILING ADDRESS) "
3 MAP & PARCEL NUMBER
(REOUIRED INFORI1ATION)
,
(from tax maps in Department of Assessment and Taxation
or from tax statement)
II ~ 2-7, I
TOWNSHIP RANGE SECTION
TOWNSHIP RANGE SECTION
TOWNSHIP ~ SECTION
TOTAL CONTIGUOUS PROPERTY IN SAME OWNERSHIP:
4 SUBDIVISION (if applicable)
/:>03
TAX LOT(S) OR PARCEL #
R-ff
ZONING
TAX LOT(S) OR PARCEL # ZONING
TAX LOTIS) OR PARCEL # ZONING
ACRES
LOT
BLOCK
5 REQUEST (state ex~ctly what you plan to do)
t.- ,\ r ~-r1r t: hi . ~ 0 0 /~. 0 IV .-
L 1/1-; nil It S r
'~i~
(!Jf1
6 DIRECTIONS TO SITE: (fur ,-l-A-fLOC() in ,0
~ 1n;Z"
I
LeFt
** FOR STAFF USE ONLY **
"
ZONE/LAND USE:
BY: DATE:
TIME IN: OUT:
NUMBER
-.
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VI
DATE 6 -2 5' '1?s.4=1
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LANn MANAGEMENT DIVISION / 125 E. 8th ^VE., EUGENE, OR 97401 / 687-4061