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Name of Applicant Signature of Applican'
6X0 Ci, Cea nave M0
Address of Applicant Applicant = No.
ACD rte jeans Lia] hcory hyoony Owher
Applicant’s Email Role of Applicant to Project
(owner, attorney, lessee, agent,
architect, engineer, contractor. . )
Property Owner:
me ee aN
| Address: by{c Qi; b. ia
-abavaat NY, TOK
Director of Development