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IT IS <br />TO <br />ALL <br /> <br /> Drawn By: <br />I certify that ~hc above ~nformafion is accurate to the best of my k~owledgc. <br />Applicant (Pleas~ Print) <br /> <br />Applicant's Signature: <br /> <br />PLANNI]qG: <br /> <br />PUBLIC WORKS: <br /> <br />~.LE~DIIqG ISqSPECTION: <br /> <br />Date: <br /> <br /> <br />