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w°0r
<br />Anadditional n 1-., incurred for
<br />FEE: + mpnemin& legal fees, publication o,.
<br />other requirments
<br />(VAtfaumm
<br />STREET LOCATION OF PROPERTY:
<br />I.EGA.1, IIS I;^;aS ]I .:ISP"I''.[O FROPI:iRl r; ,,,. ,,,
<br />:......................................... ...m,,,,,,,,,,,,,..m......... m ............................ ..... ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,.............................
<br />:P OPE . '. u „ IK.W]B
<br />FEE OVINE]"t:
<br />DD.R]I SS
<br />FEE OWNE R
<br />LEAESf 1 rILI
<br />r1111111r . r
<br />14j;d
<br />9 1
<br />DESCRIPTION OF REQUEST.
<br />By paying the above state fee, I undmamd tha no refimds wiiH ire i , in full or in pati, at any time,
<br />even if the outcome is denial.
<br />Sit of :1b � - � s` �� �� Signature f .. Owner
<br />Date
<br />eef°,i^odli"�
<br />. ��� �' �'" � it rn�17P' w ipU r�r� � iv,w ° Yrs qua V�•
<br />
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