HomeMy WebLinkAboutPR 4.51; MIHOLICH RESIDENCE; Engineering ApplicationLocA r roN oF PROJECT: oN THE I n e> MY'\ J s rnE oF I L4,. eo c..; t-o..J ·
(NORTH, SOUTH, EAST, WEST) (NAME OF STREET)
BETWEEN / L-,sd cil..fl'-Y\Ct u<y;V AND / a: 'J'--to v--..~
(NAME OF STREET) (NAME OF STREET)
ASSESSOR PARCEL NO(S) • I ~\ :S -l\ () (::)-\ C)
BRIEF DESCRIPTION OF ENCROACHMENT:
REASON FOR ENCROACHMENT:
OWNER APPLICANT
NAME (PRINT OR TYPE) W\\\\<l.W'\ ~ «:\""~ NAME (PRINT OR TYPE)
\ "' ' .. ~ \ '~ q_ vv-,Q......
· CITY AND ST~TE ("')_ ZIP TELEPHONE CITY AND STATE ZIP TELEPHONE
L~ ..\-c-... ~-·~oo9 C}312<;,,ql'j ~-a._~
I CERTIFY THAT I AM THE LEGAL OWNER AND THAT I CERTIFY THAT I AM THE OWNER'S REPRE-ALL THE ABOVE INFORMATION IS TRUE AND CORRECT SENTATIVE AND THAT ALL THE ABOVE TO THE BEST OF MY KNOWLEDGE. INFORMATION IS TRUE AND CORRECT TO SIGNATURE DATE THE BEST OF MY KNOWLEDGE.
1~. SIGNATURE DATE
"-
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FOR CITY USE ONLY
TOTAL FEE REQURIED.,,-.,r--5-D-~-c:,-o __ _,
DATE FEE PAIDj CJ, 2-7, 4 I
RECEIPT NO. j B3 18
RECEIVED BY:
Page: 6
6P..-crl-2..J i!J'G. 2 21991
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