HomeMy WebLinkAboutPermit Building 1990-1-8
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APPLICANT
MAILING ADDRESS
CITY, ZIP
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l803023300.900
TMH 416-88
FRED DALO~HN
1763 INLAND WAY
SPRINGFIELD, OREGON 97477
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1. WHOHASAMEDICALHARDSHIP?(NAME)~~~ /to _!~....e...r . 7huAJ I' -'L .
2. WHO IS PROVIDING CARE? (NAME) ,md:d~<? ~~ ~~/~./YYl;~
3. WHAT RELATION IS lHE CARE-PROVIDER n' !'t> 6' j . I
TO lHE PERSON WHO HAS TJ-lE HARDSHIP? . / -.;. 0 7
4. WHO LIVES IN THE MAIN DWELLING? (NAME)
5. WHO LIVES IN lHE TEMPORARY MOBILE HOME? (NAME)
6. LIST TJ-lE FOLLOWING MOBILE HOME INFORMATION IF KNOWN:
MAKF' YEAR: SIZE X.
7. SIGNATURER
PERSON WITH HARDSHIP
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DATE
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1. NAME OF PATIENT'
2. NATURE OF MEDICAL HARDSHIP'
3. DOES THIS HARDSHIP NECESSITATE THAT A FAMILY
MEMBER PROVIDE CARE? PLEASE COMMENT:
4. PHYSICIAN'SSIGNATURE:
MAILING ADDP"''''''
CITY, ZIP
DATE
Lana County Land Management Division 125 E. 8th Ave. Eugene. OR 97401
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