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SA1~ MrGUEL CQ~ jTNTY <br />BUILDING 6: SANITATION DE PART1~f1=NT5 <br />coot;TY AND STATE cOLES COHP~IANCE 4ERIFICA^ION <br />AND DEVE OP!!ENT PEAHI ': <br />r'*~ be cotinleted nr`^~ ''^ apnl~~at~cn f or bui2c_~c nez-r+it~ <br />Ccnp:iarce :+ith applicable County Lard Use Code and State codes <br />criteria :cr each c£ t.`.e categories listed '_:~ Sections 3 and 4 <br />rust Ze verified b•_ t::e ?lann_nq Di.ector and Bu_ld:~+y O°f'-cial <br />prior to cur.s'_deratian cf erpliodt_ors Pcr tuilding peraits and <br />solid-.::el burni::g device per~i'_5. <br />DLi:C?-.yT Sii~LL CDMPLcTE: <br /> <br />2rcoer cwtia_ ' Ma:l~ny- ;,ddress ?hcne <br />~ <br />~~ <br />j <br />~ <br />9 <br />, <br />~~ <br />, a w 2i <br />i <br />- <br />5:;~~eo~ irCCer-; _ <br /> <br />~+~ ! \ i ~ C1t~lt4~Q ~ r V ~ _ <br />_agal D?sCrl:L;~f; o: K .,_-ar-ems' <br />r- <br />.J ~+ <br />xlst:ng case(s) <br /> <br /> <br />: ~J52 (3) <br />tr CCCS E' S'.'y ~:.;2 COOL=E <br />1 <br />~~/rT ~ /~ ~/~~ <br />Lot Sipe crocosed 3ldr,. FIeiS t :fo. °aYx2: g 5ca::.e~ <br />?-'ocCSea SZ=LaCks; Frv :c S:r?e <br />.~- --- lea= <br />?rcocsed ;+ater Supply Frccosed Sewage C:s~osal sys;.e~ <br />:t_st~ :g Sol: --::el auraer ?rogoso~i Soild-''.:el Sur^er <br />I Y:ers~y certi°}•, sub;ect to oenalty c~ perjury, t::at the abcve <br />is true and accurste ;~ :.he best o' my k^cwledge and t:at i <br />~,;nderstand all pr.c•is:ons cf c:;~nty and stare codes applicable to <br />-`,e groposed development, any and all conditions placed Spa: =..".e <br />prc~osed development by the Boa::1 0° Cam:`-v Co.;Jnissioners and all <br />information requested by t':is docuae_zt. I also understand that <br />:° violate any applicayle provisions o! Co+irtty and/or State <br />cores, I may be regal=ed to remedy suet violation(s) t'.:.c:;gtt <br />aopropr:ate fecal process ixposed by the co+inty, including moving <br />o- r~virG structures ar.d ceasi^g cP construction ard/ -' <br />/ EXti~3l7. <br />S;.cnature of Applicant Date II <br />Page 1 of 2 <br />ocx _5?6 • Telluride, CO 81435 • (vfi:aznonte Bfcg., Roo..n 3I 2 (303) 7.3-39?3 • Fat (303) %~°" <br />