PERMFILE130665

• Permit No: C1981041A
• IBM Index Class Name: Permit File
• Doc Date: 7/30/2007
• Doc Name: Mesa County Dept of Planning & Economic Development -South Portal Minor Site Plan
• Section_Exhibit Name: Tab 15 Appendix 15-1
• Media Type: D
• Archive: Yes

I/13'ejrather acknowledge that we havefamllitaized ourselves with the rules and regulations with
respell to the preparation of this applitatkon, that thg foregoing lirformatian ks true and mrrect to the
• best afoot hrowledg~ and that we assume the responsibilkty to monitor the status of this'applica{ion.
lYe recognize that we ourselves, or otrr reprtwsentative(s), must be present at all hearings. In the event
that }hepetkaoneris not represented, the item maybe dropped fmm the ag¢ada, and an addi8onal fee
ckiarged to carer the re-scheduling expenses before it can beplaced again on the agenda. Submission of
• thisl~evelopmentAppGcationconsritutesagrantofpermissibnforMesat'ountyReviewBoards,Staf(
and~fgendes to eruer the subjeetproperty.during working hours and conduct such site invesh~ations as
t\h./e~(y~d~eemJ~ne//~ej7]e~sisrawry.~A~ l~lnroperty owners ace required to sign this fornL
//CO~~'Li /~•Y_Y_lNJ'ay ~~j~~( NL~OJI v r~ ~~~ •
Si of Person trorn letinlg this App&eation Print Name Date
~ ~l.~~aft~~r •jlle~~ ~ N~l_soN~ L•..KI ~ ~ ~- 2006
Srgnature ofProperty Owrux(s) . • , Print i\Tamd Dot

Signature of Property Owners)
Signature df Pippaty Owwner(s) '
Signature of Property Ownetts)
Signature of Property Ownca(s)
Signature of Property Owner(s) - •
Additional Property Owners:
Flame:
Mailing Address:
Name:
Mailing Address:
Name:
MaIIing Address:
Print Name Date '
Print Name Date
Print Name ' Date
Print Name Date
Print Name
Date
Telephonc #
G~ty:
city:
Telephone Ji
Telephonc #
ary.
A15-1-0
Zip:
Zip: '
~P~
(New 07/07)