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rd'I'LICANT : name phony 7�! <br />1 address atS/o _j "j., _e ..-.('ices.. CS✓ir�c_ 1x Interest in in properly (chock ipproprin!c b-.Ac <br />❑ uworr of record ❑ le...c, :q.('ldtur, .tanager <br />❑ caolract for Jced own," Cl .1111...... rnt 14, I'.urr.haso <br />❑ other (explain)-------- <br />Oucumcutary avidenceYof .q•plir.ant'', ialr,r•.I III the prom rry m:.y be <br />required before final city alai,"! on !hi'. <br />111:01,01TY: a.hd!"'c``,./g• n��cr qql loi•Il inn �Hf .. �4U�._ ��=�LL�a1GL—. <br />Ir,lal uwncr: <br />prusenl usr (check apprr,;n ial,• i••'a) <br />L7 unda'velt,l„yl CI bu•.°rc rt:,,!tli .!•'••ol <br />❑ sin;"le family dn'•I Iia" L1 ILiA•'•.i J! al:llaldut:lC <br />(J J"plrn -IMA 11.t ll .,•pit:•.:' <br />LJ other (explain) ..____ ................._.._...__..._ ..._.-•-----_—•— <br />xipJEST: (explain) — •tom _--- -- <br />I I:ereby declare that the above statement'. are tour. _ <br />--�—(Signature]-- <br />FUI( UFFIU: USE ONLY: <br />BASE FCFS* <br />subdivision, ma,ior ($150) +Y Sf7 <br />sub(fivI!,ion, minur ($15) - <br />rezoning (550) �ro•o� <br />conditiou,al usr ($50) _ f7 <br />variance ($SU)—_._......_ <br />code appeal (w) ..-_-.-• <br />suhlutal Sp__00.. <br />*Base fee,. In p.trenth.•'.is arc rn.n.. <br />refuuJable. <br />I'd11, hold drJirariun _ <br />daty p.1id <br />, et ri lit 11 .. <br />AI"OIilGfidL FEES <br />,'•apporliunnirnt --- <br />t.uLlir, h.•;u my dbtirci _, ._—. <br />:calf, ct:r;alumt reviews _jpa•o0 <br />a/r(o orwilall subtotal <br />ISp - --_ <br />SD iGUcL III:. <br />3170 receip! n l(iTSY' <br />