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" <br /> I certify that the above information is accurate to the best of my knowledge. <br /> Se d-I-J--- I <br /> Applicant(Please Print)-• -- -i -i-s/45',1•1/4:r . • <br /> Phone: fn 7) r'4:• 971) <br /> • . 4 , , <br /> •:mailing-Address: ,2e,e-i i'lmeg,tiele. g it 40:6:600 <br /> __,, <br /> , _ <br /> : <br /> Applicant's Signature: eel •-t"----C-1 Date: • <br /> -----.....4.< . <br /> FOB OFFICE USE ONLY <br /> • • <br /> PLANNING: <br /> . • <br /> PUBLIC WORKS: .Date: <br /> BUILDING INSPECTION: • Date: • - <br /> MC. IS-(DO • • <br /> Ref sigs 53. 3 - f56/- J ,2 .Ptic," . • <br /> . .. ....... _ <br />