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HomeMy WebLinkAboutPermit Building 1985-12-31 , 1_' I; ,;-) '.. " 3) ?~--",..,'/ f ' 0~~~'~~:~ I;.{\: ~..~ - ~ (' "6). ..cll- - \)V ",'l--W'.:M. ' I I: \. 0'}\V~l\S\~~ .. /0.. \) \',~\.l" A ' INFORMATION PROVIDED BY THE APPLlCAN"T '0/{-;c.i,1 \ \~\; Person with medical hardship e:....P~,j &nL.1j~ , ~_c- U Person providing care ,~<-4A __ U ) ~' Family relationship of the above ~.J ~<S ~"~, Resident of the principal dwellinl'; \l../.LI~ '!.JJ~oCJ Resident, of /he temporary mobile home () j!? L ..; .1.J ,~,A ,~fu-U Signatures \ 'Date: . l Person with Hedical Hardship QJ2 A/~ d!~ . ~on Providing -Care ({' " _.~ -"'r,:;-;,~:-,:. ----.~-'-'--;,; .;:.,: ~, I , .' c."' ..5-'.' '.:--:. ~';; '\r-"~': ~,\I~h-.t:; Kenneth'Woolery"",.,,. , .' "I . '4655 ':Ja~;'erRd,:", < i..:".;, "",::' I Spfld"0R 97478 ""'3, '~}','~,:: .' __de :":;'< ~t _'\~"i 0:L.':~~~: '- '< ~ . APPLICANT: . MAILING ADDRESS: RE': Temporary Mobile Home Map/Tax Lot No.: Permit Number: . dlo'R-If,<-t \)<,- fJ,.:::)-\)/'S \ ~O 1 CITY, STATE, ZIP: " 1) 2) 4) 5) 6) Date: /a-c96-Z~ INFORMATION PROVIDED BY THE PHYSICIAN OR THERAPIST 1) Name of patient ~&b~ ' :)9 ///l:'~/U, _ _ C~--v, A ~~ .' /' ~~ 2) Nature of the. medical hardship ~A_~ I v. Does this' hardshIp necessitate that a family ~b~r provide <:.8."re? ,Please comment: (/1~ L' -4. , ~--"'- ~~~ ." , r-'" ....~~- ,~ ,/L-~A - ~~/ ~,~_ ,,/, Y8 . Kn:'!'~ Hb'~' PULM Y INTERNAL MED E 1110 NORTH 18th . iPRlNGFlELD, OREGON/97471 ~' 3) 4) Physician's Signature .-/ / Date/y/.7/'i/ Hailing Address: City, State, Zip: :,f'-cJ2-0J: /-..7"""" ( .?t?CJcJ :s 1 c-d , uA~o- LAND MANAGEMENT DIVISION I Public Works Oept, I 125 E. 8th Ave., Eug. OR~7401 (503)687-4061 F' ~~ L. WO~LERY ~. J l 4637 JASPER ROAD' . l' s~.~~~G.'I~~D, OR. 9747 ';; ~~.J~ _' a;tt, r: f//L~1 ;{ ~d 71l ~~~LUUJ /)~~~ p~ W~ ~. - e g~.'_ /1... /dd;? (,-, ~ $~LL/ ();€ C; 7c)D) - . \c--/ -, , -:.' - - - ': - , - \ ...~--..-. ~~.,- ..- - .-. .~. " \ ' J,