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Vir' '( , DEPARTI,ENT OF ENVIRONI1ENTAL 11ANAGE~IENT
PSB, 125 EAST 8TH AVENUE
EUGENE, OREGON 97401
. v '
Job Address / C? ..s:-s~..-.-, h ../ ~~ l' C1ty
towns1lip: Range. Swt'QC". lax Lot /,.f -0 ~ -O.=? - , "'i7J ..-:::
SutidtviSl?n /V ~ _, lQCf
Appl,catlOn for P./././~/~
Structures now on the property ~
PropO$OO use Ocf PAl:' () ,l!,,;id$1t;'al' 0 COllllle",i~l
Affldavlt!, Ii r:~.rt1f
(pfJt;il print)
If thlS appllcatlon 1S for an agrlcultural bUl1dlng It wlll be used for purposes allowed by the State BUlldlng Code and
Lane County Code Chapter 10 (zonlng) and for no other purpose I have the followlng legal lnterest 1n the property
~owner of w;;.ec rd, contract purchaser, lessee, holder of an exclu51ve optlon to purchase,
dulyauth e to a.fj~r~~~wner, wt:!.B rJi);fOletdt9;:t.e oj :hlS ~PplJ:;6;'!_tlOn J .I1(
"9nature/Address ,tfM.JJ./lLI'iir-<ZQ}/ifr /B,(f.5 4-~ ~4~1 d-'~ (llO) tf1-'I9 r
Telephone '1--!J.h 19 '~r or .relte /i:.;;; ~ ?f":f
When perm',1', rea~no:sY1~_.. iJf[ Appllcant {} Owner /~/ Contractor Q.t '1ZJ mall /~i phone"'
Owner ~""'Y:r (ZlO) I Phone
ContractorJ J.v6JAl____ (Zl D) Phone
Contrdctorls OSR# Plumblng by ~,~~~
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4#-
1 ApP"c.~~ # Q
,,,C-;;t 7-7 I
A~~ig~ed NO~b.~
BloCk
CI lndostnal
o l>o61Je
. hereby certlfy that th,s lnformat,on ,s true and accurate
If Commerclal 1/ of .tlIr1l\$
Resldent,al ~ of bedrooms
SI test holes ready
OU Nor WRITE BELUW
# of employees
rHIS LINE
1/ ?! unlt$
50S: ~xlstln9, BP #
/~I Proposed. 51 #
I1Mt
Cast
Fee
Code
S<j. Ft. or
lle$Crlotilm i/ of SIte.
(
<<hrL-- ~ 1-;:~ 0n0/J P .
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(/?/"~z 0-/- 14Jj-5-~7)
n Cuh -,1I7(3f
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~ecelved by / -45'P /#-
y ~,,-
Water Supply ~
Proposed EXlstlng
Year Installed
/
Total Valuatlon
l>l_fl1l1 flll.tures at
s.werlwater cOnn. at
$
$.<~
$
Valuatlon Fee
~
$
$
$
$
each $ "'~ '0
each $
$
$
Sed/_~O
$
$ .s:~.t2
Subtota 1
4% State surcharge
Pl ans check fee
Change of Occupancy
TOTAL
PERMIT PROCESSING
Mlnlmum setbacks
Zone ~~
t, front
Part #
Parcel #
Parcel S1ze IJ/ /J-
t, slde
. lnt
rear
,
Comments ~ 11/J I../J/) )
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CP&I
To be
/ ,/1_
Type "? -)J Group Ie::.. - <:, Flee Zone .::;:;
- -..--
typed on permlt _. _ _ ~ . ,7 h'
O--Al.JJO.f'-r~. A_'- I~~'
,1- (r'" - ~ d r' /
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By ~A'..d~ ./
To be typed on permlt
Use Class,flcatlon
Date
<) ,c 1\
9-..:2t?-?C7
, ' ,
-'~" , ~...;:-
C/ SIFO
)!{t CP&I
CI WPC
C/ Plannln9
~I PubllC Works
() Elevatlon CI n/a
CI Address
() Facl 11 ty Perml t
~/ Envlronmental Health
.---. , /" b'
By '7:17/> Date T -Z-q....-/9'
For plans ,nformat,on call (area ,nspector) t:#N~.IV Phone a7~O
OlrectlOns to slte~~/ /.A"./ ~/~.Lf:~ h' ~7 ~_.....ar-Z:; ~/7<-,/~~
, /F" /" '
Plans to CP&1 =It(S) Date Hold sl Date Date to
WPC _ t(s) Requlred to P Completed PCC
FOR INFOpr~TION about progress of your appllcatlon call
C74-171
Permlt Control Center
687-HELP (687-4357)
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