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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 />-42441 <br />DO NOT WRITE IN THIS SPACE <br />Subdivision <br />Filing Unit Block <br />If not in a subdivision: <br />TownshipLS Range P-W Section ! /J <br />Date Received: <br />Application # <br />Fee $ Ck# <br />Physical Address of Properly 3 City?*Kf5r4L St ,0 Zip _9? <br />(If not known, may be obtained from the Mapfng Dedaf 719-836-42$8) <br />WNER INFORMATION ' ' Affew - 5- l Hnlc eor W fj4A50C-N- SAW PCB'- 5q <br /> <br />City TA 1l I S L- State 0 %__L Zip ? -. <br />Phone (?t9 ) 3? - ?S May wee mail or fax your permit to you? <br />E-Mail Address FAX <br />INFORMATION /? ? <br />0JAE? t?rTL.E V Fi <br />Address .1 . 0 • L , <br />City State Zip 604i - it <br />Phone (7 1, ) 8 3 6 b Fax( <br />May we e-mail or fax the permit to you? <br />E-Mail <br />ill bWNA2E hereby declare that I <br /> <br />DW AE?fC5 <br />?N (?t? Srn?iE <br />s <br />am the owner, or author/zed agent of the ow?4er, of t/?e <br />property for which the dr/veway permit is requested Also, I have racelved a copy of the Driveway Cut Plermlt <br />InformaWn aryl I understand that it s my r ibility to comply with aff rules found in the Driveway Cut Information <br />'r <br />OWNwAPPLICANT'S SIGNATURE <br />Directions to the Property <br />ou <br /> <br />Revised 6/06 4