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j i.!...ti,. <br />wY ' ~ ~ ~ ~ LANE CdUNTY DEPARTMENT dF PUBLIC WdRKS ForCff~~~vs~vnly <br />APPLICATIdI~ ~FDR FACILITY PERMIT ~ ~ DATE; <br />1 . , ~ ll~Cd~Rf~L~F~`~I~PLfCAT~dI~~ ILL 1~dT~,I~~~Cd~~f~`Q <br />SEE PA ~ ~PER~#T`# ; ~ ~ ~ FAR II~S't'RfICTIGNSA[~~ FE`S a~ ALAt~S Mt15T B~ ~ ~X~~ CR Slt?ALLE~ t11~f.E'SS AN Frf.F'CTRQN(~ G(~PY IS FRCVIUF.f~ <br />Cr~xa~Etf~E~E ~ ~ . ~ . s <br />E ~ APPLICANT: Print Name ~ ~ PROPI*RTY~QINNER: Print Name lif different from p icant~ E ~ ~ 1 <br />E i 99 East Broadwa #406 ~ ~ <br />. Mailing Address: 5tceet Address Mailing A ress: Street A Tess <br />Eu ene dR 91A~1 Dity, State, Zip: Code ~ City, State, Zip`Code~ <br />541 6825249 341 682.632 . <br />. ~ ~ ~ay~me Phone {Required} FAX Daytime .Phone Requi } F' <br />~ 54~ 5Q1-0352 ~ <br />Evening Phane ~ t Phane ~ ~ vening Phone Cell Phone~~~"~~' <br />ns,d.olson Ci.eu ene.or.tas: ~ ~ -mail Address ~ ~ mall Address ~ ~ . <br />~ ~ ~{~}Road; name Nottin ham Ave {3} MAP TAX L4T : .17 ~ ~ g.4 0~ ~ Og ~To whip ~ Range S Sub ax Ld# <br />I . {4).Street address cif not addressed put N1A~; NIA. ~ A►~proxirnate Mile ~ Post of Road ~ Nearest Town <br />~wiw.rwrrrrr r r.r rrrjn.rrr ~ r ..r.,r~.~..;...,, ~ : {b}~~irections to site from nearest.major cross road East; on 5 ~ s1n Creek road ahen,a - no~amatel ~ 6B5' nor#h to Nattin hang <br />Ave ~ ~ ~ . <br />3 i ~ ~ <br />. r <br />~ ~CHECff ENE BdK BELd.W rHA T BEST DESCRIBES 1"HE WORK Yd U P[.AI~ PFRFORMAI~D aTI~aCH ~~QUIRED~ flfAt~Rf~LS 7 ■ ~~~rrli... •~.1. 1 <br />i . •(8) DRiVfV~AY ARRAN p~RM~: YDU MUST COMPLETE A~ H HE~aw1F YQU HAVE CHECKED THS DRlYEWAY APRON B~3X. - <br />a. Attach a plot plan 11x17 or smalle~~. ~If you ark buflding or crave ~ pfar~nfng acf~on, furn ~n ire dame plan ou- wfli p~vid'e. f~• Lan~f # <br />~b. ~Chaase doe; ~ ]Cons~ru~ing New Approach [ ~Modiiying ~ F:ads#ing Apps oath [ ;JEvalua~on Hof E~asting Approach ~ . <br />c. ~1~tdkh~~ofdrivevua access~atthe ro ill e . ~ . y~ . , p ~~y ~ (ff no,~ch~ce ~ts madG ~~r~, wflrpr~vr~'e ~y~u with ~~#be~ raPnfrnum re,~urnmen#~ <br />ron Surraoe R ueslr As haft d~ ~:AA ~q ~ ] p ~ ]Canarete [ ~Cra~el'{~~sp~haf#=ar con~~efe frnish is nequ~r~d oi~ paved roa~fs~ f E <br />. e. Haw many tax lots vu~Il~ this access serve? ~ Haw many accesses ourrentiy~exist? <br />. ~ f, . S#aking or flagging of the area is required. Describe haw the access is marred; <br />. .g. ~ls this permit a requirement for A Building Permit?~Y ❑ or N. ❑ A Plannfng ~4~ion? Y. ❑ or N ❑ ~ffyes~aftach condifions of approvaf ~ ~ . ~ ~ ~ <br />' ~ : h. Describe the u ase o~ the aa~ss? {ex: home,. RV parking, industrial} ~ . p <br />~ i; Addifional Comments ~ ~ . . ' . . <br />! ~ RdJEC ~ . ± {9}~ ® T DEVELdi?MENTERdAD CdNSTRUCTIdN PERMIT: Engineered plans and surety may be.required ~SEI# REVERSE} <br />f i 5 ~ . ~ ~ ❑ RdADSIDE LdCCINC PERMIT: Staking. or flagging of the area is 1requi~d. Describe Shaw the location is raarked <br />~ s • ~ ~ _ <br />~ i ~ ~ togging Co. ~ Pf~one ~ - ~ ~ ~ : Mailing ~Address~ lnduding Zip E „ ~ <br />Describe Logging Activity; . 3 <br />{llj~~❑ UTILITY PERMIT: Submit 11X17 or smaller engineered plans.MUST.mark locations with~Paint:vr fl i ~ . Work drder# <br />. X99 n9 . . ~ . , Approx mile post Desari lion of Work <br />P . ~ ~ <br /> <br />~ , . <br />i F <br />{ (~'z) dTf#ER wdRK.~VViTHiN THE RIGHTMdP-wAY:. Work in the right~of way not covered above. Phase describe the work in.detail. Attach~:aaite . . <br />~ p[an and supporting matedais. P1ea~e stake or flag~the area • ~ ~ <br />i <br />~ ~4pp~ic:atiori is hereby made for a~fad~ty ~t~for wottc fo be dene within a Cacmty Road righter-way, subjer~ to ~I terms, ca~tior~, agreeraen~, stl~aUans, ark provisions of the issued <br />permit. p~cEaa# fia.t~e:. ~ . ruies~and reg~ations t~ga~rig roads atxi ri~ts-0f~ray; asset forth ln~l~ne Code 35 '?25 and L~te'Man~d 3.120.124 and 35.505550; and ~y atha applicable regi~ation,law, <br />a ord'rtanog.'rhe'uruterst~ed <br />~ : tydedares, certifies and a4firti3s ~xidec'penalty~lawitiatatl.irtfarma~on prv ai #~s menis ate, tothe bestaf myi~nvwEedge, true.atid ~mpiete. ~ . i <br />E . s SIGNATURE Pro eo 0 ~ f d ~ ttine~ aulhonzed a ~ of P nY ~ 1 ~S~ d~ ~o date <br />~k ~j i ~ RETURN Td: Lane Cauntjr Public I~Iforks En ineenng Permit Desk, 3x44 N. Delta Highway, ugene, dR 91448 <br />Tel.5411682-6942 F 5411652~85Da Hearing impaired 5411682-3995 , <br />Lane Coul~y cows YM~tlStaie ~ Fedeoa! taws and j +~~o~r~,~iat~~w~ca~s+~►~s~r~~s,~ttaon ~f~sa w~orra~tror <br />I <br />