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Type of A,�plication: _Special Permit �iance _Other �f /� �
Project AddressTt� (1����� L„r�i—
Assessor's Parcel Number(s) �Z g" Z'�/ .3 " 2�6
APPL/CANT
Name: �
Address: /f�
City/State/Zip: �
Telephone:(work)
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(home) '
ARCH/TECT/DES/GNER
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Name: �{�(-tt�_� r i%� �D�vS r����(% ci�
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A FF/DA V/T/S/GNA TURE:
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I hereby certify under penalty of perjury that the information given herein is true and correct to the
best of my knowledge and belief.
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,� L'-/G�
A plica 's ignature Date
I know about the proposed application, and hereb thorize the above applicant to submit this
application.
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Property Ow er's Signa ure Date
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Date Filed: � Fee �l � Receipt � • "��y�����
Letter(s) to applicant advising application incomplete:
Date application accepted as complete:
P.C. study meeting (date) P.C. public hearing (date
P.C. Action
,zisz Appeal to Council? Yes No
prqapp.frm Council meeting date
Council Actio
PROPERTY OWNER
Name: -�14�' '' �
Address: C �S , G�-
City/State/Zip: ��x�,}�, C_ r,L �i- `f�/O
,
Telephone:(work) �1/�7���'y�fcff�
Please indicate with an asterisk l•1 who th ontact ver on
Address: I �S� �2�-v ; �t � i��
' is for this nroiect.
City/State/Zip: l:, w�r�c>2 ��/.� _ �`f�i 1�''
Telephone (daytimel: C�; i 6) �� �-"? r l"�