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APP#�s� <br /> Date <br /> (for office use only <br /> CITY OF PEQUOT LAKES <br /> LAND USE PERMIT APPLICATION ( / / <br /> Natne of Applicant� 1ICE m / Phone "� O�/7�1G► <br /> Mailing Address P. Email <br /> City,State,Zip 7 muot kdLe-s' MA). 66Y'7� <br /> Applicant is: Title Holder of Property. <br /> (if not applicant) <br /> Legal Owner f� <br /> Contract Buyer () (Name) <br /> Option Holder () <br /> Agent () (Address) <br /> Other <br /> ( "ty,State,Zip) <br /> Signature of Owner,authorizing application(require: 4��' <br /> (By sigmng the owner is certifying that they have read and underst 'ow accompanying lication.) <br /> Signature of Applicant(if different than owner): <br /> (By signing the applicant is certifying that they have read and understood the instructions accompanying this application.) <br /> Location of ro erty" volved" this request: <br /> 5(0. r�4/ <br /> Property Parcel ID (#on Tax Statement) /&/Q�l a o/,I OOC> <br /> Zoning District_&,-C-. ,Lake Name <br /> State nature of request in detail• (What are you proposing for the property? If a new dwelling,indicate <br /> nun#ser of tones and fo tton type.) <br /> Approved by the Zoning Department: Date: <br /> REV: JAN 2005 <br />