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Address Qj f�✓ ;�I 'G ! OG/O
(Street) (City) (State) (Zipeode)
Telephone
(Business) (Home)
Contact Person U�, /1 - /S A
Address 3501
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(Business) (Home
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(Fax) (Mobile/Cellular)
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Projec Name and rojec escri tion•
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Street Address or Bo ndary Description:
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Legal Description: (The legal Description must be correct or the application cannot
be processed.) Attach if lengthy. ,
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Check Applicable Items:
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I(We)certify that I(we)am(are) miliar with applicable state and local codes and ordinances,
the procedural requirements of e City of mes and have submitted all the required information.
Owner's Signature: Date: S
Preparer's Signature. Date: 527"/0V