HomeMy WebLinkAboutPermit Miscellaneous 1990-2-20
APPLICANT
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MOBILE HOME TEMPORARY PERMIT RENEWAL.
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. ..1702361001100
HIH 94-88
LEO ESTERGREEN
8676 MCKENZrFHWY.
SPRINGfIELD, OREGON 97478
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MAILING ADDRESS
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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.
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7. SIGNATURES
PERSON WITH HARDSHIP
DATE
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1. NAME OF PATIENT' !~~J-'.~,,~"""~~I/~ ..~~. ,
2. NATURE OF MEDICAL HARDSHIP' ;,: ,~~> \;....."'~
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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
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