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HomeMy WebLinkAboutPermit Building 1990-1-8 ~'~~~~~y) - -' .- APPLICANT MAILING ADDRESS CITY, ZIP ~. IT RENEWAL. ~' , :? ;.:.... . . ". .~", '" .', .". ~ , ."..000............._...__/ -"-"'__a. l803023300.900 TMH 416-88 FRED DALO~HN 1763 INLAND WAY SPRINGFIELD, OREGON 97477 , 1,,,,*,,,,,,,..8"'''''''';''''''"''''''''''.,,,,,,"",,,,,,,,,;c''!ii'(NFORMA TION PROVIDED B.y APPLICANT llillie",,""'''''''';'''''"''''''''''''''''H'''''''''''''',,! 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 L1CENSE# DATE ~-P,I1~~ ~~N~~:DEDI~:~~~ z-Zfj- ,{) 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 l'UJ3 T Y\ l C--hd W(U"'j