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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 /> nr <br /> /1 <br /> . . . . :t <br /> . . . . A 5- <br /> f514J'd-,`". <br /> . . . — ` <br /> - e <br /> jj. . • • l <br /> 6 Nem <br /> 1 00 • <br /> 6-0 ' <br /> b 6 <br /> ,a d� <br /> A, <br /> • - <br /> I certify that the above information is accurate to the best of my knowledge. I AM THE [AlOwner [ ]Authorized Agent <br /> Name.(please print): t v n 1 i Y i bgef My telephone number is: 503 ' CHI '03q•gApplicant Signature: � %Ey l � Date: ' <br /> Applicant's Mailing Address: 1S(,2 Ll'[1 ti d City: AtIrl 1%1 l l< Zip: l7?J Z5 <br /> FOR OFFICE USE ONLY <br /> PLANNING: Date: <br /> , PUBLIC WORKS: <br /> BUILDING INSPECTION(Acceptable for Planning requirements only) Date: <br /> Page 4 of 5 <br /> A-33D <br /> Rev. 05/2011,09/2012 <br />