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~"~- .~ Block: No, Acres:.__ <br /> <br />6 <br /> <br /> inf <br />I certif, ormatmn ~s accurate to the best of my knowledge, <br />Appliean~ (Please F'rbai) <br /> <br /> FOR OFFICE USR ONLY <br /> <br />PLANNING: .... <br /> <br />PUBLIC WORKS: <br /> <br />BUILDING [NSPEC'TION: <br /> <br />MC: 15-60 <br />Rev, 11/91 <br /> <br />Date: <br /> <br />Date: -~. .... <br /> <br /> <br />