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FACT SHEET
Current Owner of Property as listed on the deed (if other than applicant):
Name &Address
Title deed reference: Book& Page#3CE1(j Jt2 5 or Certificate#Land Court Lot# Plan#provide copy of recent deed)
Use Classification: Existing: 202.5 #
Proposed: 202.5 #
Is the property vacant: (J O If so, how long?:
Lot Information Size/Area: i cio)q Plan Book and Page Lot#
Is this property within the Aquifer Protection Overlay District? Yes No '-
Have you completed a formal commercial site plan review(if needed)? Yes No '-
OtherOther Department(s) Reviewing Project: Indicate the other Town Departments which are/
have/or will review this project, and indicate the status of their review process:
co\c>.Q f J`- o - 14-Q Q''f0V-PCf
e-c`-c
L,"c-k. k t v\
Repetitive Petition: Is this a re-application: MV If yes, do you have PlanningBoardApproval?
Prior Relief: If the property in question has been the subject of prior application to the Board of
Appeals or Zoning Administrator, indicate the date and Appeal number(s)and other available
information. Include a copy of the decision(s)with this application:
Building Commissioner Comments:
li ,Gust_...,_(-9---,,—Apr(licant s/Attorney/Agent Signature Owner's Signature
Address: L-IM -UYI't Pcinok 6(
Phone S 0 If '11/4 1 7
E-Mail:
1/°4-
7-
Buildin C sioner Signature Date