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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 /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> Ste_ ail-et ake(krf 4-e- r f et-v•\. <br /> I certify that the above information is accurate to the best of my knowledge. I AM THE IX.] Owner [ ]Authorized Agent <br /> Name(please print): 3 0Q. Cl) -�eArc fila_ My telephone number is: 65O' •S-09 •'MSS <br /> Applicant Signature: (of J 6 Date: Ala.Gli (1 <br /> F. <br /> 22. <br /> Applicant's Mailing Address: 414M VGr Poi 120( N E City: S1'I tkQ A(V fr\ Zip: 913"8" <br /> FOR OFFICE USE ONLY <br /> PLANNING: Date: <br /> PUBLIC WORKS: <br /> BUILDING INSPECTION(Acceptable for Planning requirements only) Date: <br /> Page 4 of 5 <br /> A-33D <br /> Rev.05/2011,09/2012 <br />