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· srr~ VLA~ VOa x'~OX'OSZ~, n~vz,~ovvn~ n~ MAmO~ <br /> <br />I.~__ Block: <br /> <br />Subdivision:. <br /> <br />Zone: Map:. <br />See: ~ T ,,:,,, ,~ ,, ~ Range; <br />NO. Acted: 3/.~ <br /> <br /> tI~ ¢~,.o..:L ~." ~:~,,~ ~y: .~,, ~:, <br />that the above haformafion is accurate to the b~st of my knowledge, <br /> <br />Applicant (Plea~ Print) <br /> <br />Mailing Address; <br /> <br />Applicant's Signarare: <br /> <br /> 15- <br />MC: ils <br />Rev. <br /> <br />PLANNING: <br /> <br />PUBLIC WORKS: <br />BUILDING INSPECTION: <br /> <br />Phone: <br /> <br /> , Date: <br />FOR OFFICE USE ONLY <br /> <br />Date: ....... <br />Dam: <br /> <br /> <br />