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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 /> . . . . . . . . <br /> F . . . . . . . . . . . . . . . . <br /> I certify that the above information is accurate to the best of my knowledge. I AM IHE [Y] Owner [ ]Authorized Agent <br /> Name(please print):Je Sh tt IeJI' My telephone number is: 3— 5 5 C - S 6 2,g <br /> Applicant Signature: A41-49g_ Date: /V!lam'rC ` Z g 2©Z1 <br /> Applicant's Mailing Ad ess: 2b 31 D Mc )11 % City:a Das film, oz. Zip: 013-35 <br /> FOR OFFICE USE ONLY <br /> PLANNING: Date: <br /> PUBLIC WORKS: <br /> BUILDING INSPECTION(Acceptable for Planning requirements only) Date: <br /> A-33D Rev.05/2011,09/2012,2/4/2020 <br /> Page 4 of 5 <br />