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<br /> By signing, .the undersigned certifies that he/she has read and understood the submittal requirements <br /> outlined, and that he/she understands that omission of any listed itemmay cause delay in processing the <br /> application. I (We), the undersigned, acknowledge that the information supplied in this application is <br /> complete and accurate to the best of my (our) knowledge. <br /> PROPERTY OWNER OF.TAX LOT: ~C.Y~ <br /> f~ Cobu~-y (~d ~ <br /> Name (print): ~ a,Lu1~ ~ ~1~V'~. Phone: ~ 0 / ' ~ <br /> Address: ~ ~ ° . r [?~(v <br /> City/State/Zip: L.~ C~ c.~ ~ v ~ ~ ~ ~ ~ . <br /> Signature: <br /> .PROPERTY' OWNER OF TAX LOT: <br /> Name (print): t~~n v1 y~Phone: ~ ~ ~ ~ ~ '"7~ <br /> Address: ~ IP f ~~'?JY) <br /> City/State/Zip: ~ ~ . ~ ~ ' <br /> Signature: <br /> SURVEYOR: <br /> Name (print): ~ ~ ~~p~ Fhone: tD D a c~ <br /> Company/Organization: ~,q~~~~i1.~'?~ <br /> Address: ~ S O ~Qft.,l" ~ C~.. <br /> City/State/Zip~~ ~ E-mail (if applicable)•-}-~m ~ -~~S~Qr~ ~GC. 2UGP.f'1a .QI~. (LS <br /> .Phone: Fax: ~QO a•^J~S~ <br /> Signature: <br /> REPRESENTATIVE (If different from Surveyor): <br /> Name (P~t)= Y I C~K..t 2 .l..C~`11~5 <br /> Company/Organization: ~1'}~. ~~~i(,(l ~/f'l,Q <br /> Address: ~ i'.Q.(,~~ <br /> City/State?Zip~(,/~~E-mail (if applicable): ~(C.~'.l Q~ ~ , Q,(,((,1~ . Or u5 <br /> Phone: ~o~-((~C~~ f Fax: ~P go•1--J~S~ <br /> Signature•~ ~(.~.c.G/ <br /> Property Line Adjustment Date Last Revised: 1/2006 Page 3 of 3 <br /> Application Form ' <br /> <br />