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HomeMy WebLinkAboutPermit Miscellaneous 1990-2-20 APPLICANT . ~ Off\: Lav5 MOBILE HOME TEMPORARY PERMIT RENEWAL. <t If!1 ~ . ..1702361001100 HIH 94-88 LEO ESTERGREEN 8676 MCKENZrFHWY. SPRINGfIELD, OREGON 97478 JSMI) , ~ ."' '. = ..... ''', ~". ~. ". ".:".:, ," ":::-",. .......................:......0..-,..,.,.1 0.-"_"'__". v'v\c-~Vl1..it.- ~l-( "J ~'~~~~ty) - .' MAILING ADDRESS CITY, ZIP V'*"'"'*tiill:':"""""""'M",=",,,"~",.,,,,i INFORMA TION PRO VID ED BY A PPLICANT "..""..~..""".m":'''''':';''''''''''M"',:p,..,.,~,."" 1, WHO HAS A MEDICAL HARDSHIP? (NAMI=) 2. WHO IS PROVIDING CARE? (NAME) 3. WHAT RELATION IS THE CARE.PROVIDER TO THE PERSON WHO HAS THE HARDSHIP? 4. WHO LIVES IN THE MAIN DWELLING? (NAME) 5. WHO LIVES IN THE TEMPORARY MOBILE HOME? (NAME) 6. LIST THE FOLLOWING MOBILE HOME INFORMATION IF KNOWN: MAKF' YEAR: SIZE X. L1CENSE# 7. SIGNATURES PERSON WITH HARDSHIP DATE *-1k-k:l~NP~I~~ JCfl6,(I~ ~ WO' - .~,:;;,= ~~DEDP.':~~~,C:: ~~~p~~~1 . . ~~~D 1. NAME OF PATIENT' !~~J-'.~,,~"""~~I/~ ..~~. , 2. NATURE OF MEDICAL HARDSHIP' ;,: ,~~> \;....."'~ tjJ~'~\~~\"~;~~ . j\8~j ~~}~'"''\.'\ \~'-<~:\' f2 "t"'" 't<..' ~.~ ......'."'~'\ \'\>..'''' ~.,.' >\.: . ... .(,to" _..r:'~.I....,\ ~~\;,~\~\\., ~:~ ~~I 'I}jY . DA1'E c.n 3. DOES THIS HARDSHIP NECESSITATE THAT A FAMILY MEMBER PROVIDE CARE? PLEASE COMMENT' 4. PHYSICIAN'S SIGNATURE: MAILING ADDRESS: CITY, ZIP /, p-/- ~j/%c); LBnB County LBnd MB:Z=:;B ement DIvIsIon 125 E. 8th Ave. Eugene, OR 97401 /1 )1. /7 ~ ~! ~ . ff~ V~'_ /75 ~ /> /-.-t:J . -/ 1c:J}'J . /' /~ C---~-</./ d ~ /T - ~'It.-