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Environmental health Department <br />BOX 216, Fairplay, CO 80440 <br />Main Phone: 719- 836-4267 Inspection Line:719- 836-4265 FAX: 719- 836-4266 <br />E-Mail: vmumm@parkco.us <br />Tax Schedule # <br />-.42-f6i <br />Subdivision <br />Filing Unit Block <br />If not in a subdivision: <br />TownshiplZ5 Range Section <br />DO NOT WRITE IN THIS SPACE <br />Date Received: <br />Application # <br />Fee $ Ck# <br />Physical Address of Properly 313.1 City_ Rt L St .? Zip 90441 <br />(If not known, may be obtained from the Mapping Dedartment. 719 836-4288) <br />WNER INFORMATION Affow - S=!ONIte Cox W n4a5ac-N swPCR-SR <br />cud <br />City State W. Zip <br />Phone ( ??q ) 3? - ?S May we e-mail or fax your permit to you? <br />E-Mail Address 4- FAX <br /> <br />INFORMATION f C L f ?Y <br />q CKWOOM M4ek <br />1 9 ?y <br />.-? ?• . w <br />city HAA-r6ft_ <br />ZjP C)U!f 11 - --A <br />Phone ('71, ) 8 3 (o- Fax ( <br />May we e-mail or fax the permit to you? <br />E-Mail <br />ILA <br />I, am% Dvw__a?Ju hereby declare that I am the owner, <br />D1-D A??e5S <br />/N 9"C' <br />?04t <br />AS <br />or authorized agent of die owner, of the <br />property for which the driveway permit is requested! Also, I have received a copy of the Driveway Cut Permit <br />Infonnation and I understand that it is my respombdity to comply with At rules found in the Driveway Cut Information <br /> <br />OWNER/APPUCANT'S SIGNATURE <br />Directions to the Property <br />Revised 6/06