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SITE PLAN MUST SHOW ALL PROPERTY LINES AND DIMENSIONS <br /> ❑ Drawn to Scale: 1 square= Feet Not Drawn to Scale:Total Acres <br /> I certify that the above information is accurate to the best of my knowledge. I AM THE [ I Owner [authorized Agent <br /> Name(please print): &1Cr -Ic.,ze n\pe My telephone number is:503-899-0094 <br /> Applicant Signature: ) Date: 12-6-2022 <br /> Applicant's Mailing Address: 82 Champoeg RD City: St. Paul Zip: 97137 <br /> FOR OFFICE USE ONLY <br /> PLANNING: Date: <br /> PUBLIC WORKS: <br /> BUILDING INSPECTION(Acceptable for Planning requirements only) Date: <br /> A-33D Rev.05/2011,09/2012,2/4/2020 <br /> Page 4 of 5 <br />