20060507 Ver 2_More Info Received_20081014

Part 5: Applicant's Certification
I, M#XV -rle4?-Te / I lWAIM s s&F- (print or type name of person
listed in Part I, Item 2), certify that the information included on this permit application form is
correct, that the project will be constructed in conformance with the approved plans and that the
deed restrictions in accordance with Part 5 of this form will be recorded with all required permit
conditions.
Signature:
Date:
Title:
Bole 19
?t I d ?008
DW•wAMOMM
W gttOS AW ST012MM140 WAW;"
Variance Request Form, page 4
Version 1: February 2000