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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 /> • • •5•C-<— 06-eke--4 <br /> . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> I certify that the above info lion is accurate to the best of my knowledge. I AM THE Owner [ J Authorized Agent <br /> Name(please print): ass-e. a i+.-- My telephone number' 5 is: 03—SO 7—S/S <br /> Applicant Signature: Date: 5i 3©/ZOZ3 <br /> Applicant's Mailing Address: /3 53 9 -// "i� es /ee / City:fp.142r7,r7. Zip: Y9-B3— <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 />