HomeMy WebLinkAboutApplication APPLICANT 4/29/2008
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City of Spnngfield
Development Services Department
225 FIfth Street
Spnngfield, OR 97477
TEMPORARY USE - Emergency Medical Hardship, Type II
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??1~fI/ tJ~ Phone: !>Y/-6:?~-6f'3-:r
11:;);l~ i,- Sr: .5/,/'~ (J1f 771'177 Fax:
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Property Owner: I DtrYZ-nA:1-- /n. W?../~ Iphone: l6'ff :206-:749?
Address: 11t>t(,o. ~~.-4. a I Fax: I
ASSESSOR'S MAP NO: 1;- tJ "3 - 3:r/~ TAX LOT NO(S): // / (J 0
Property Address: I:J ;;2.:K' ,t'". .:S 7: :SP4Y-?r/ f).f?,. 9 7 ~'7 7
Type of Living Unit Proposed: , 0 Residential Trailer .l8l!,"~1 11~i1;~..L . J(J RV ,1$1
Applicant Name:
Address:
Specific Description of Proposal: f 0 ~ ~ <-r ~;t-~ ~
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The undersIgned acknowledges that the informatIon In ~hlS application IS current and accurate. .
Applicant Signature:???~ !lflJ ~ Date: 9'-;;) /-0 x:-
If the applicant IS other than the owner, ~ o~ner hereby grants permission for the applicant to act In his/her behalf.
Owner Signature: Date: C1~:; (/,'JotJff
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Ca~ No.:
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Date:
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Application Fee:$
Technical Fee: $
Postage Fee:$
(\ Date Received
TOTAL FEE'S $ Lu~ ~c~ 1'G2-< PROJECT NUMBER:
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5-8-2007 BJones
Onglnal SubmIttal
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CIty of Sprmgfield
Development ServIces Department
225 FIfth Street
Spnngfield, OR 97477
Phone (541) 726-3759
Fax (541) 726-3689
Income Requirements-Fee Waiver
Temporary Use- Emergency Medical Hardship
APPhcantNamOJf~ ,;/ rJt1ffi~ Phone6....11-5~O-6C;35
Address I::J~~ 13/ ST.; s,~+4 /J~d 97-Y77
Property Owner Name ,j) 1"f">o7A'1~ '777, c1j 5-) ~ .."
Address Cj IJ ~ ~ ~ ??/ A If? C c' ,,(;, - Jl:,f
S/'R,'/t!.:J ;,~,<~ ~0 97 L/7!~ Phone6Y/'"--;( tJ G-~/fY?
Property Address I ,;2 ~ dE. .$'/:,) 5,;r' /,,, 'rJj7 h.L<"# ~r <1 ? ~ 7'7
Assessor's Map No I >-1 -- 0 -0 -.3S II-f Tax Lot No Lj. / (J D
cr1.. /7-03 - '3$//
Annual Htlusehold mcome of Property Owner ) / 1,00 0 , 00 5 ~ ~
Annual Household mcome cannot exceed j f)....~ . kJi:? ../ '" 0
1 Person Household $19,150 $~ ~...-.......-~ / I~ ~OOr
2 Person Household $21,900
3 Person Household $24,600
4 Person Household $27,350
5 Person Household $29,550
6 Person Household $31,750
Current Pay-stub or Income InformatIOn
SPR' GFIELD
The underSigned acknowledges that the InformatJon JD
J~,/Ufl VIS6~
APphcantSIgnature~d'?l~- ;f, LJcf~ Date /f-'d./- 0 Y'
If the applIcant IS other than the g:er, the owner hereby grants permIssion for the applicant to act ID his/her behalf.
r Owner SIgnature j?fo--,,~ In , 'Ua~~
DateD jOpwA :2.1,/ J ~ () 0 <<
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Journal No
For Office Use Only:
0Q. C "2G-uCb- bUD 32... ReceIved By
Tax Lot No
~
Map No
Date Accepted as Complete
Date Received:
APR 2 9 2008
5/8/2007 BJones
Onginal Submittal
,
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FORM SSA-1099 - SOCIAL SECURITY BENEFIT STATEMENT
2007
o PART OF YOUR SOCIAL SECURITY BENEFITS SHOWN IN BOX 5 MAY BE TAXABLE INCOME
o SEE THE REVERSE FOR MORE INFORMATION
Box 1 Name
MONTYH WALLACE;
Box 3 Benefits Paid In 2007
Box 4 Benefits Repaid to SSA In 2007
Box 5 Net Benefits for 2007 (Box 3 mmus Box 4)
$13,200 00
NONE
$13,20000
DESCRIPTION OF AMOUNT IN BOX 3
DESCRIPTION OF AMOUNT IN BOX 4
Pmd by check or cluect c1eposlt
Benefits for 2007
~13,200 00
~13,200 00
NONE
Box 6 Voluntary Federal Income Tax Withheld
NONE
Box 7 Address
MONTY H WALLACE
1625 HENDERSON AVE
SP Ell
EUGENE OR 97403-2325
Box 8 Claim Number (Use thiS number If you need to contact SSA )
Form SSA-1099-SM (1-2008)
DO NOT RETURN THIS FORM TO SSA OR IRS
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5 Cr"//U 4 {
Onglnal Submittal
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ComprehenSIve Healthcare
Under One Roof
John V Ahlen, M D
PatncIa P Ahlen, M D
Jeffrey D BeckWIth, M D
Lana Gee-Gott, M D
DaVId 0 HeItter, P A-C
Anna C HejIman, M D
Martm Hurtado, M D
Douglas P Jeffrey, M D
Sally S Mane, M D
Mark S Meyers, M D
Damel K Paulson, M D
Eva R, SchmIdt, FNP- BC
2280 Marcola Road
Sprmgfield, OR 97477
Phone
(541) 747-4300
Fax
(541) 747-0655
Busmess Office
(541) 747-8576
www sprmgfieldfamIly
phYSICIans com
Springfield Family Physicians
Apnl 22, 2008
Date Received:
APR 2 9 2008
Re Harry Wallace
Onglnal submittal
To Whom It May Concern
Mr Wallace has been a patIent of mme for over 20 years HIS current
medIcal diagnoses mclude, HypertenSIOn, FIbromyalgIa and personal
hIStOry of Colon Cancer
At 96 years of age, Mr Wallace IS begmmng to have problems WIth
balance and galt He IS also begmrung to show early SIgnS of
dementIa, mvolvmg memory problems
It IS my medIcal oplllon that Mr Wa1lace would benefit from havmg
someone on SIte to help hIm With hIS actIVItIes of dally hvmg,
mcludmg meal preparatIOn and transportatIOn
Smcerely,
~~.~
John V Ahlen, MD
DIplomate, Amencan Academy of Fanllly PhYSICIans
Spnngfield Fam.1ly PhYSICIans
~\
FORM No 961 _ BARGAIN AND SALE DEED - STATUTORY FORM tLA - Ltl-b 1..)6 STEVENS NESS LAW PUBLISHING CO PORTLANU UK WWWSlevel""">>~'"
r-----m-- -----;:;aPART oF"- rEVENS NESS FORM MAY BE REPRODUCED IN ANY FORM OF ~Y ELECTRONIC OR MECHANICAL MEANS ~
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Alter reco~dlJ9' return to (Name, Address, ZIp)
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-f1-O-b-.(,-e---/4--A-R-&-tJ-LA-----ft-~J---------
----~-~-~-----tf~-----~-fJ1-17-~----------------
Until requested otherwise, send all tax statements to (Name, Address, Zip)
DIvIsion of
Lane Counly
~~~~ ~~_~~~~~~-------------- } ss
I certify that the wIthm mstrument was
receIved for recordmg on -------------------------,
at ____________ 0' clock _____ M, and recorded m
book/reel/volume No __________ on page ---------
Chief Depuly Clerk "nno nt' ~OAO. -"
Deeds and Records 'UUg.U wg,g
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------------------Grnn~rs-Nameand-AddreSS-----------------
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----------------1~-.:rv:-------^XTV------'\jl7rcT::A-C7::.---T/7:.CfF-O-\T---fJ-6!--------i\T--2T---q-x--' Grantor, ;,.1
c09{ey~ to -J~{/-j~---~- --~~J/;t~---------~------:-A------------~-r4---~-~J-\--__j__________12_L~_l______~~tJCL-------
__~-/~~}Ct-~~~----~----~J----~------~~-:r-,L5-~~-------------------------------------------------------, Grantee, I
the foJ\owmg real property sItuated In -L-A--W--E-------------------- County, Oregon, to-WIt I
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0'9842242'0:00158480010012
03/21/2008 10:41:16 AM
RPR-DEED Cnl=l Sln=6 CASHIER 07
$5 00 $11 00 $10 00...... __
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Beginning at a potnt on tne North line otnE" street in Springfield,
LIDe Oounty. Oregon, &8 8st.bllsned by Registered Title Instrument
No. 41630, 8aid beginning point being 1020 teet East ot tne East
line ot loth Street; running thenoe East along the North line ot
nBn Street, 60 teet; thence North 120.27 feet, parallel with the
E..t lino or lOth Street to the Sontb line ot the olley running
Beat end Weat between "En street, and "pH Street, thenoe Weet
along tbe South line ot said alley, 60 feet, thenoe South parallel
with the East lble ot lOth street, 120.27 toet to the plaoe of
beslnnlng, in Lane Oounty, Oregon
(IF SPACE INSUFFICIENT CONTINUE DESCRIPTION ON REVERSE)
The true consIderatIOn for thIS conveyance IS $____Q____________ (Here, comply WIth the requIrements of ORS 93 030 )
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
-------DATED-~~_-_~~~w~~-CL~~~~~_=_~~~=~~=~~~~~~~~-;i~-~~~-;;;;~-~~~~t~~~-I~-h~-~~~~~d~~;-~~~-;;b~-~;~~d-~~d~;;~~~~-If
any, affixed by an officer or other person duly authonzed to do so by order of ItS board of dIrectors
BEFORE SIGNING OR ACCEPTING THIS INSTRUMENT, THE PERSON TRANSFER-
RING FEE TITLE SHOULD INQUIRE ABOUT THE PERSON'S RIGHTS, IF ANY,
UNDER ORS 197 352 THIS INSTRUMENT DOES NOT ALLOW USE OFTHE PROP-
ERTY DESCRIBED IN THIS INSTRUMENT IN VIOLATION OF APPLICABLE LAND
USE LAWS AND REGULATIONS BEFORE SIGNING OR ACCEPTING THIS INSTRU-
MENT, THE PERSON ACQUIRING FEE TITLE TO THE PROPERTY SHOULD CHECK
WITH THE APPROPRIATE CITY OR COUNTY PLANNING DEPARTMENT TO VERI-
FY THAT THE UNIT OF LAND BEING TRANSFERRED IS A LAWFULLY ESTAB-
LISHED LOT OR PARCEL, AS DEFINED IN ORS 92010 OR 215010, TO VERIFY
THE APPROVED USES OF THE LOT OR PARCEL, TO DETERMINE ANY LIMITS ON
LAWSUITS AGAINST FARMING OR FOREST PRACTICES~ AS DEFINED IN ORS
30930, AND TO INQUIRE ABOUT THE RIGHTS OF NEIGHBORING PROPERTY
OWNERS, IF ANY, UNDER ORS 197352 La.
STATE OF OREGON, County of __________[l_~___________________) SS
ThIS ms~~~~was 'E~;:tedg~d before me on _____/'JIYA,~__-za~2QQlL_____________,
by -----------Jl--------)L----------l~~-----------------------------------------------------------
ThIS Instrument was acknowledged before me on -----------------------------------------------,
by ______________________________________________________-----------------------------------------------
as ________________ ------------------------------------------------------------------------------------
N()~~~~~:ifi?~:::---cl--------------------~~~~o~'"~:::::::::::::::::::::::::::-
MY CO~~~~II~;~~I~g ~~~~~~ 2011 . My COIIUlllSSlOn expIres ______5_~~t_~_2:Q1J_________________
~-~~~~----------------------------
tLA)~_~_'i--------~Li'=-l:=ll-s-~------------
---------------------------------------------------------------
PUBLISHER S NOTE If U~lng thIS form to convey real property subject to Oregon Laws 2007, Chapter 866, Section 3, Include the reqUired reference
Date Received.
APR 2 9 2008
Onglnal SubmIttal
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Date Received
APR 2 9 2008
Onglnal Submittal
~
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Onginal Submittal
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WILSON HEIRGOOD INS
PO BOX 1421
EUGENE, OR 97440
MONTY H WALLACE
1625 HENDERSON ST #E-ll
EUGENE, OR 97403
Date Received:
'..,
1
APR 2 9 2008
Onglnal Submittal
Auto Insurance
Coverage Summary
This is your Renewal
Declarations Page
/'
.dJ:W~.
I NSIJRAtlCE FROM PRO!JRE1JIVE
Polley number
Underwntten by
Progressive ClassIc Insurance Co
November 24,2007
PolICY Penod Dec 18, 2007 - Jun 18, 2008
Page 1 of 2
541-342-4441
WILSON HEIRGOOD INS
Contact your agent for personalized service
dnvemsurance com
Online Service
Make payments check billing activity update
polICY information or check status of a claim
800-925-2886
To report a claim
The coverages, limits and policy penod shown apply only If you pay for this poliCY to renew
Your coverage begins on December 18, 2007 at 12 01 a m This policy expires on June 18, 2008 at 12 01 a m
Your Insurance policy and any policy endorsements contain a full explanation of your coverage The policy limits shown for a vehicle
may not be combined With the limits for the same coverage on another vehicle The poliCY contract IS form 961 OA OR (06/06) The
contract IS modified by form 7962 (03/02)
Dnvers and household residents
MONTY H WALLACE
Outline of coverage
1994 Dodge Ram 25004x4pk
VIN 1 B7KF26C5RS571182
Liability To Others
Bodily InjUry Liability
Property Damage Liability
Personal InJury Protection
Unlnsured/Undennsured Motonst
Uninsured Motonst Property Damage
Comprehensive
ColliSion
Rental Reimbursement
RoadSide ASSistance
Total premium for 1994 Dodge
>
FOfln 6489 OR (11/03)
$250,000 each person/$500,000 each aCCident
$100,000 each aCCIdent
$25,000
$250,000 each person/$500,000 each aCCIdent
$10,000 each aCCident
~~~~~~:"?f~~J*~A:~~~~" ~w
~SJ"R~CE111:!~!HffilC.I\I!Q~Mf~2~g:>
ipohcy Number 66547944 5 Effective Date
Ilnsurer Progressive ClassIc Insurance Co
POBox 6807 Cleveland OH 44101
Your Drive Agent i'''l ;.,
WilSON HEIRGOOD INS .' '~ ~
541 342-4441 1: II:" f;;' f,i1."'~
Naryte of InsLire{J~~~iVl,,'f;.*"~'<-.;?'-'-~-'-<.2;
MONTY H NAlLACE
Additional mformatlon
Named Insured
Limits
Actual Cash Value
Actual Cash Value
Deductible
Premium
$215
$0
16
5
3
$200
$300 hit & run
$500
$500
17
48
18
8
$330
12/18/2007 to 06/18/2008
Vehicle Year Make
1994 Dodge
Model
Ram 25004x4pk
J it:;1 iF {~ j Ie r ""'I..~r;
VIN
1B7KF26C5R5571182
Form 4950 OR (09/05)
I
Continued
Date Received"
APR 2 9 2008
Onglnal submittal
CR00748
T~AVEL TRAiLER REGiSTRATiON CARD
TITLE NUMBER FUEL TYPE IFARM 10 NO I
0117795222
STYLE MODEL VEHICLE IDENTIFICATION NUMBER
NEW EXPlqATION DATE
'PLATE NUMBER
HVUT DATE
SEP ~O, 2008
FEE
YEAR MAKE
1987
COLLI RT
EQUIPMENT NO
WEIGHT/LENGTH
TITLE BRANDS
LG 25
- NONE -
$182.25
ODOMETER READING
ODOMETER DATE ODOMETER MESSAGE
*WALLACE, MONTY HARRY
---906-60-MA"RCOLA KD
SPRINGFEE-LD -QR----97-4 7-8-=-8-7-04
1{7 'j - ~ 1//' r} N 1\ I. 1111 0 I{ t/ ct , c. ,;3
NEW ADDRESS (HOUSE flUMBER s-id~~T:C(TY ~~lfE ZIP ~~6E)7 J ". -:j
COUNTY OF RESIDENCE
LANE
COUNTY OF USE
VALIDATING STAMP
V:l\';~ U
NEW PLATE NUMBER
,'" \;-"- [11--
;.. ~f~ p-i.. ~l II l0 l--
~r-t tL::\~)tehl;?.1
NEW STICKER NUMBER
L ~O'7~L6-J
OREGON
PLATE NUMBER
TITLE NUMBER
prSSB~GEE flEGI~TRA~10~
PROCESS DATE EXPIRATION DATE . FUEL TYPE
~ '";;,
EQUIPMENT NO
TSD33S 03237?~L~~
YEAR MAKE STYLE MODEL
0:26(8 ~~R O~.~C!O
VEHICLE IDENTIFICATION NUMBER
DTE::E.L
WEIGHT/LENGTH
J. :1 ':J tOO:)'::;
TITLE BRANDS
F'lJ
r!'Z5
IB7K~2~C~R3~7~182
OWNERI
LESSEE
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COUNTY OF
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COUNTY OF
USE
NEW
ADDRESS
LII i OF SPRINGFIELD
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DRC2008-00032
1222 "E" Street
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SITE
Map 17-03-35-14
Tax Lot 4100
North
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Date Received:
APR 2 9 2008
Original Submittal