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APP# <br /> Date 7 <br /> (for office use only) <br /> CITY OF PEQUOT LASES <br /> LAND USE PERMIT APPLICATION <br /> Name of Applicant 1r'AC-Y- W, SJO� Phone (.Ne;) 831 -,910-S <br /> Mailing Address 3032A 5TAR, 3-71 Email <br /> City,State,Zip UQrd- VW ) Z <br /> Applicant is: Title Holder of Property: <br /> (if not applicant) <br /> Legal Owner <br /> Contract Buyer () (Name) <br /> Option Holder () <br /> Agent () (Address) <br /> Other <br /> (City,State,Zip) <br /> Signature of Owner,authorizing application(required): '�& 4&�— <br /> (By 6gnung the owner is certifying that they have read and understood the instructions accompanying this application.) <br /> Signature of Applicant(if different than owner): <br /> (By sigping the appaicant is certifying that they have read and understood the instructions accompanying this application.) <br /> Location of ro erlinvolved.in this r <br /> 2 ruvaS Douce �dc�+:�Lbi^ S15 -r%3&0 2-9 W <br /> Property Parcel ID (#on Tax Statement) <br /> Zoning District ,Lake Name <br /> State nature of request in detal: (What are you proposing for the property? If a new dwelling,indicate <br /> number of stories and foundation type) <br /> C,L pug <br /> r���e�. Go c— <br /> m v Q we- <br /> Approved by the Zoning DepwVaent: Date: <br /> REV: JAN 2006 <br />