HomeMy WebLinkAboutApplication APPLICANT 6/8/2020City of Springfield
Development & Public Works
225 Fifth Street
Springfield, OR 97477
SPIRIMGF1ELDAr
TEMPORARY USE - Emergency Medical Hardship, Type II
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Required Project Information licant: complete
this section)
Applicant Name: ic.�.a.e� ice!
QYawv�
Phone: 4S&- Z3 -1
Fax:
Address: G6-5 S-�!! S .
Property Owner: a-'w.e.s A Mc,1o�r cl•i {F �� Phone:
Address: slys F alre�t' Fax:
ASSESSOR r A%NO: TAX LOT NO(S): ) -Oa, �✓' ;Z —moo
Property Address: t -(4S -f7 S -f{ j' fi`e-fid 89
Type of Living Unit Proposed: ❑ Residential Trailer ® Travel Trailer ❑ RV
Specific Description of Proposal:
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The undersigned atknopriodges thatthe I,nf�ormatioon i/tthhisapplication is current and accurate.
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IDate: ; c0
Applicant Signature: �1 �
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If the applicant is other than the owner, he owner erebv grants rmissbn for the applicant: to act In his her behalf.
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Owner Signature: a (Date: G�a �ze ag
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Required Property Information (City Intake StaFf., complete this section)
Case No.:
Date:
06/08/2020
Reviewed by: Liz M
811-20-000109-TYP2
Application Fee:SF33-8--1
ITechnical Fee: Ei 6 9-0--1
1
Postage Fee:
190
544'90
TOTAL FEE'S
PROJECT NUMBER:
Re .d: 30.14.13 kl
Date: 06/03/2020
To: MICHAEL P BROWN
5195 F ST
SPRINGFIELD OR 97478-6166
CERTIFICATE OF INSURANCE
New Hampshire:
This certificate is issued as a matter of information only and confers no rights upon the certificate holder. This
certificate does not amend, extend, or alter the coverage, terms, exclusions, and conditions afforded by the policy
or policies referenced herein.
All Other States:
This certificate is issued as a matter of information only and confers no rights upon the certificate holder. This
certificate does not affirmatively or negatively amend, extend or alter the coverage, terms, exclusions, conditions,
or other provisions afforded by the policy referenced herein.
In the event the policy is cancelled prior to the expiration date, notice will be delivered in accordance with the
policy provisions.
POLICYHOLDER
LA Dept. of Ins.
Cert, of Ins.
Assigned LDI No.
MICHAEL P BROWN
in Louisiana:
LDI
COI
POLICY NUMBER:
-
EFFECTIVE DATE-
ATE0079139581
0079139581
06/03/2020
06/03/2021
ISSUED BY:
-- "--
FOREMOST INSURANCE COMPANY GRAND RAPIDS, MICHIGAN - NAIC# 11185
POLICY TYPE
UNIT COVERED:
-
TOWABLE
® VIN ❑ HIN: 51Z812220RR061247
LOCATION ADDRESS:
5195 F ST, SPRINGFIELD, OR,
97478-6166
ADDITIONAL INTEREST #1:
-
LOAN NUMBER:
SCOTT C BROWN
ADDITIONAL INTEREST #2:
LOAN NUMBER:
Coverage
Bodily Injury(BI)............................. $
Property Damage (PD) .................... $
Combined Single Limit (BIPD)....... $
Personal Liability ............................ $
Personal Liability ............................ $
Other Than Collision Deductible... $
Collision Deductible... .................... $
Watercraft Deductible .................... $
Total Annual Premium: $ 352.00
Limit
(each person) / $ (each accident)
(each accident)
(each accident)
300000.00 (CSL)
(each person) / $ (each accident)
500 (n/a for watercraft)
500 (n/a for watercraft)
.(watercraft only)
To obtain additional policy information, please contact:
Agent Name: DUNLAP T R ENTERPRISES CORP
Telephone Number: (541)744-0556
For Certificates issued
LA Dept. of Ins.
Cert, of Ins.
Assigned LDI No.
Date (mm/year)
in Louisiana:
LDI
COI
733421 04/11
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