HomeMy WebLinkAboutApplication APPLICANT 1/6/2023(City of Springfield
Development & Public Works
225 Fifth Street
Springfield, OR 97477
PERMIT REVIEW INTAKE FORM
SPRINOFIfi
(City Staff completes form)
Permit Type
Dept of Motor Vehicles -New: ❑ Land Use Compatibility Statement: X City: ❑
Dept of Motor Vehicles -Renewal: ❑ Zoning Verification Letter: ❑ UGB: ❑
Project Information
Applicant Name: Andy Au Phone: 541-513-6000
Company:
Cell:
Address: 720 3511 Street Unit A Springfield Or 97478
Property Owner: Black Label LLC
Phone:
Com an
Cell:
Address: 79 Centennial Loop Eugene 97401
ASSESSOR'S MAP NO: 17-02-31-21
TAX LOT NOS : 2601
Property Address: 720 3511 Street Unit A Springfield Or 97478
Description of Proposal: LUCS for OHA for psilocybin extraction, fungi cultivation, edible
Psilocybin production
Record.
Record No: 811-22-000004-TYP1
Date Received: 1/6/2023
Application Fee: $ 365
Technical Fee: $ 18.25
TOTAL FEES: $ 383.25 Assigned Planner:
Revised 112.11 k1
PUBLIC HEALTH DIVISION
CENTER FOR HEALTH PROTECTION
Oregon Psilocybin Services
htto://oreeon.eoy/osilocvbin
Land Use Compatibility Statement (LUCS)
Section 1 - To be Completed by Applicant
Ith
Applicant Name:
Andy Au
Phone:
541-513-6000
Mailing Address:
720 35th St I
UniUSuite:
Unit A
City:
Springfield
State I
OR
I ZIP:
97478
Premises Address:
1720 35th St
UniUSuite:
Unit A
City:
Springfield
❑ Inside UGB
State:
I OR
I ZIP:
197478
❑✓ Site plan of the subject property and proposed development attached?
License Type:
F-1 Service Center ❑d Manufacturer
Property Zoning:
Manufacturer Endorsement:
(If applicable, check all that apply.)
❑J Fungi Cultivation
Psilocybin Extraction
FV� Edible Psilocybin Production
Section 2 - To be Completed by Local Jurisdiction
Site Location Information:
Map Number: Township 17, Range 02, Section 31, Tax acct.# 1654639 Tax Lot Number: 2601
'Include Township, Range, Section, and if applicable, Quarter -Section and Quarter -Quarter -Section
Name of Jurisdiction:
Oregon
Property Zoning:
301 industrial Improved
Site is Located: I
❑✓ Inside city limits
❑ Inside UGB
❑ Outside UGB
The proposed land use has been reviewed and:
Comments:
To be completed by Local Reviewing Official:
Name: An)b✓t Lt M 8r 0_l�
Email:
Signature:
❑ Is prohibited.
❑ Is not prohibited.
Title: S >-PLANA)M
Phone: 5L -1j 72 (& 3781 f
Date: / / b I'1v 23
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