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Situs Address: J3~BqO Irl~gl~"/ha. ~J.~ ~qa~_$~.. zove; :~I~ <br /> <br /> Lot:_, Block:. <br /> <br />................ !.......).~.....~..-:..,.k...:..~: .....;;.......! .......:. <br /> <br />Subdivision <br /> <br />Map: <br /> <br />, Ra~e: [ ~] <br /> <br />Drawn By: <br /> <br />MC: 15-60 <br />Rev, 11/91 <br /> <br />Scale: <br /> <br />I certify that the above information is accurate to the ~st of my knowledge. <br />Applicant (Plc~ase Print) ~/.'q~-l~. ~. ~'~}~(X'~'~, <br />MailingAddmss: /&q 10 _& CO -~C-~SCA~L~.-V~,~^, T/8~afl ~ qTZg¢-, <br />Appli¢~£'s Signature: __ ~,~/~q' ,~/~--"-~_.,'~,~.M <br /> ~'i'~ ' | ~ ~OR OF~CE USE O2Wr <br />PLANNING: <br /> Date: <br /> <br />PUBLIC WORKS: Date: <br />BUILDING INSPECTION: Dat~:, <br /> <br />Phone: '~-'~" <br /> <br />Date: <br /> <br /> <br />