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HomeMy WebLinkAbout046-180-001P • - '• � /�^:oa `:d r r'� f .paw �I Pr / P ill _ , • "i e V . crvi • . ;'�: ly ..tl. +Y •y i r 'r n - elr. �t vv i �.. �1 i 11A 1 Y � , dr it NOTICE TO APPLICANT rD p iti ` y. ,If app is tither than owner, a�proof of agency must be sUt.piied in w, ng „ in on r to legally Is the Appifcation #or U,�e Permtt/Variance C r f'i �• 11 r �:d r � r Application on shall be�oonsidered void (f not sighid by owner or his legal a5ent, i o j i ,r All Items on application shall be. completed, If an Item Is notapplicable,ipdirj Y i bate by the symbol n/a, f� 3. Explain briefly yet completely the''naturo,of-tho proposed uoe-variance, This is very Important and a requisite.(, lY my A. Ten copie's of a detailed lot 10an folded 8'/�'''X 1I"shaty ) accom an and be }1 made a part of the "Appllcatiot� for Use Permit Varlance�i } ' !i J The rplotplan . shalt include the f61LoNti'lj ! � a, A scaled drawing of the parcel (s) bound arles. ,.� ,l . 1 t. b, Location of till existing and proposed buildings and Improvements, 4,.E c Locatitri'�and site of existing and proposed access to the subject paicol(s), d, .identify streets bordering property and nearby crossroads, Provide a loca, On map It necessary, Show North Arrow, M. Applicant she 'II further understantl that tQ "Appliotitior for Use Permit��,.j uponVArlanap appeal, of the Board oft supervisors, Any s66soquenhe i spec mission, or ` A pp � g co�idltlons`` pl? � -�Commission � 4 r o a I be ordered y tpp oVed.. "Use Per6nit/Varlointce"sand shall bebindingori the appllcent, °f the r gti Unless conditlons of approval have been compiled with, lita one-year perlod,�,e i the "Use Permit" will be deemed bxpired, y i hereby declare under penalty of Arjury that 'l have read the forogolgt, r Vit„ instructions and sta�vments and understand their ffieaning and context; bATEm {I 191V_17 y �'t r -c :r n (Ilppil�sntl ,I Nod Cb. 016ntti00 rottt,nr broville, COforola is t J: t ,r �r n NOTICE TO APPLICANT - 'VARIANCE ', 'Ordinance No . 1313 r^ I i.` AN ORDINANC� MENUTNG ORDINANCE N0. 47 r KNOihrN AS THE BUTTE COUNTY ZONING t;NABI�ING ORD CNANCE ►'I16. VARIANCES from �:uhe tet`ms of the zoning ordinance 'Y ,IShal.l be granted only when{ because of special circumstances LicaUle to the property, including size, shape, topography, p✓J C 1 p tlo.kj' or,� ,surround'ings,, the P strict application of the zoning , .ordina(hce deprives s'uoh prop��erty of. privileges en ed by other ,, f t ei: ty in the vicinity and under identical zoning'" c�.assifa:c.ation". Any variance gi'ahted shall be subject to such conditions !) �, ill assuro that 1110 ad j ustine4t the by authoriz,od shall not . ivileg.o�i inconsistent with the urat,V.i-ute a grant o spec �a pr _ s 'Upon. othor roPertd.O� ' t=pari s in 'th-6 vicinity' a d zone in ch such property is situated, Any .such condition imposed,' upon issuance of a vary once z� t s,t be reasonably reiatod to the use be granted i q .u.:.t t�f the property `"dor whic3s the variance �s �.e erte shall not. for a parcel c ',Property .. ich duthoxizes 1,n use .or aptivily which is not othorwlse ��esly authr��:., by the ee regulation govt�nng the parcel I �� , �,�_Ips^.cpei:t�'►�, I7EDY DtCLARt DNntA ptXALTY off' ptAj JRY THAT I HAVE RtAn FG�ItOnTNC xNu'Rt1CTI0N5 AND 5"AT1,lEriTar1n UNt7RTA1Vi7 MEANING AND' CONTE?'l ��:.`,� ✓-{'":art'.-t� ate 1, on 1517 r, �M,a p`roville Galifornla S t t , 1 e j E ;&Pp'�NDIX 1.6; If residential, ixtclttde the number of units, schedule of unit s%zes ,; and type of hd4sehold size expected. 17 . cpmmer'cial`, indicate the type, whether neighborhood, city or regionally oriented, square footage of sales area, and 1.0adang facilities.,,a 10 ({ 18. if industrial', Indx.cate type, estimated employment pat shift, andloading facilities,, 19;. If institutional, indicate the majo;4i, unction, estimated employment- per shift; estimated occtzpanc�i', l.bading facill"t,ies and 'community benefits to be der ` Y iV�ed fr'nmthe projectr, 1r fib, if theproject involves a Variance, rcond, tional use or rezoning application, state this and indicate cl.e46ly wh*r the application is j requx ed; Are the following items' applicable to the p'ojactSor its effects? ii,,,scuss below all items , checked yes (attach 'ctdit.ional sheets s aTy YF,; NO , �,:�.. Change in existing features of .y beaches, lakes, ., ,. or hilj7 ' , cr substan;tial alterat ion of ;roun& � antaurs , nificant: chang in scenic views o� vistas fro F , ex7.stxn�residential areas or public lands er toads. "�3S1nalcatttly changescale 4, ". patt6�:n, or character' of anoyal ai�eaof pro ecyL. 24, Si,Bnificantt amounts of solid. waste or litter. J 25, CYtange, itt dust, ash, Smoke, futttes ear odors in `y� Y vic�,nity, � 16 . •8ignificant; change in lake, stream or ground vattr j�' ,quality of quatltity, or alteration of eklstiii �iraJ.rta�e patt.ptns : 8ubsta:tttial change in e•. n �toise vibration` -- :r . ' : ...:est l . l.evel.s in t.he+ vicitl�.ty,tti ft I of 3ptrcelit tn.�{ Site on filled lret p ot :4 ley 29: Use or disposal of p6tential'i-� `kta.za,rdbus ttatetl.a.�"S" t , such as toxic substanoes, flammabl,es for expl,08ives,I, + t1 I P1 �?► ryry i, , r: YES 30i Substantial change in•, demand fo uni.cipal services fpo.xce, fire,, water, sewage, etc.)": .' 31. Substantally increase fossil fuel consumptr:on ? (electrica.ty, , oil,-`, natural "4as etc.) . ]� 32 , Aelationship to par� ��a larger project or series . rf projedts« ENVIRONMENTLL SETTING i; 38. Describe the project site as .it exists before the project, nclOOIng information on topography, soil. stability, Plants and animals, and any cultural,:, historical, or scenic aspects + Describe any exist,inq structures on the s' .te, and the, use of the 5tructu °es 3.9.. Describe ,the surrounding properties, including infotmation on plants' a0d animals and any cultural, hisi,orical or sceniic aspects. Indicate the' ty��e of land uses (residentia;;l, comuercial, etc «? r intensity of land use (one -family, apartment, i�iouses, shops,, depart�tne�it 8 tares,, `1�s etc") , and scale of development `(height, frontag�'i, et -bask t'e$x;e ard, etc.) r lig <CER�i2�x�AT�ON: � 11er�b 'C��t,�,f that., the sta•�C'.� E''�,E.5 furnished - x y ` .. A C�. and the attached e th�ba is present the data and information. y,�r� g ed i±ox this initial evaluatxoh'i,�to the best of my, and �the that ,,_ _ ,abili.ty, ,(facts, st'atementa, and infokmmation presented are true- a'�ci correZt to ti#e ..Jest of My knowl,edg(g and bellef , a , )4, ,•� 7 k�or i \ t !i t( � It �ppend.� page 3 !:of 3 , i r 1 y°1`r,' a IY,.aay;J,;',�P fi 1�tiT'' ?i•aa ' ift ./E# ,lar i'.,*r N i 19 0 t b -, 'pts / -•a 7� Q Q+ �5 l� /�� to 'r t oyf j W qy' (� , C!)1' 7 wlh �1+ or fy that YOU �Y'�) tt�a bv)��;r of bdbm ttitya 1�b'+'t0 a'ra�`, j't�Clr3rd`'LdbCUtiZ�;°nt5 I't wi 11 be tjecssar.tlr ... {} � �� �u t '�� 1 ���n� da�.rys an ,ya:Ut v"�r7rtcC .,,t�' i��t�,r�n o Setts �^ o t� on hisu�� d' ybu. have fly-�qups `•� 5 i'n re r6 y i w; 1 Bdi tty , Cl c lbIf ro r , { ,�. k° eo i C � r W0 j p' ,,� 0 44 U ,E • t11 U cd A �$ tH 4-1 rd o Ilk 03 46 U t ` f ">tm m T w W • �, VJ •`Y ''v'T/,,1 „ 'may „ I 99 t -i 4, « ro I'� I Ll L,}j, M olli i11 , , s% .. tt isBch V2x' �' ,, c ti �q .N cu, �7t cu a Lol `pq x « aaC ro -P•rq .0 P4 r^ rb��i 1 A I y' , , ly`�.,, ►- t"Q11 � tl1 tom' O � p ,� I w F -a r - r 4•t a� w M o 0G�l 0© d1 .� iia rt 0) (31 tI- ii m Gq oq�i `, '''` `f') off' LL. ^pl [1j l7C pql Iv rrt %� q © 11 F4 WcL CL 60 �" d od I' ,: ii ,I1. ,� a r.}... ci i,) Lv . I " 1 H' ; d r n : ,1 , �c� _ 1.? r^,, „, .... >,_ _. �Y4 .. ,:... Cir �:-. ti t, _ •?.:' »:ter i17 a .. . [t ..11�,.- a,X . - - 0F220Q'' PACE93 in m Id N. d O 1 UY]� �W 4 to �� J C.0 U n ccl L a.'el O = CL 1 W tik � Uj bor. W_ w � C v a CL Jy NOr- b E �%4 to r A 4 s N .;o •� Y Jz - �r lY i, , 0c, n r �QCto r 20"AND OF NATUR'A1 ,i Nf AITH t,ND BEAUTY' P-tQVl toNMeNTAL REEK-w"a EARL D NE1.86N pirecto BrJti' / txc� mes 1300 Salem l Chico95926, 4 ... Re Ca`tego:rical Exemp �z,on' 4&18.,»01 Dear Mrm James: Enclosed �,p.L ' with the 7BuEteSCaunty CY,� ex onf Oche '46tice o� EXemptiaa fit f & • exempt f ram en+tri. bnmlltal rev eu�7aridya7s w rea to This p:ro�- Adcsche'dulec for hemp`, dy • �ustm.ents ?� y thy;' Butte -.Colin y Board of Zonibg date with th e ab b r The hearing � set f o� Navembe yp"'ed he bpdy has `been, 9, X97,7 at 9.00 , aim,. 4 lobated at �1 0bttu -,y� Center :irive; Oroval7�ai�r Data prooe;ssin Conference oom) �a ' Should have t e:ftt, nes z"egard�z is thPvOject, please 4 contact this deparmh 14 r. 40 1 Earl. D. Nelson; r; Environxmealp nta , 1 , : enolo c, r it f • f r 'k.� � ! " - :-f•• a �`•� s i �' /� ♦9 "��a han�r'�iG1,�.74�y7 �• _ ._vas >�'r �� � t I , -0 i :i , )UTTE COUNTY ,BOARD ,OF 'ZONING ADJUSTMENT. ' NOT F UB _IC ,EAR Mtr"... Notice is hereby ^given: by 'the Bute County "Board of Zoning Adjustment that publ icr;hear-ings wil l be held on Wedne`slday, November 9, 1977, at 9 -00 a.m., in the Data Processing Confi�,ygnce Room, #1Gg County Center Drive- 0roi ille, Ca1ifat'niap� re ardng the i=ollot� t C1 rg� 0 hx--,-. . ITEM DETERMINED "TO B GAATTEGOR ICALL •-,X SMP: R M7RVTR_ffMENTAL REVIEW ._ 1% James 0,. Bruce - Var i a n c e to a11ow a building 31,i eft. , from ,the "c;an t,er1 1 -he of C Street :and 43 ft. fromthe t� „ cent.erl9th St. on property 2oned,,"A-211 a (General) located on the northeast corner of 19th St. and C Street, identified as" AP 46-18w01, Chian. 4 The aboV,ement�dne ppTications, peti��i�nsz 'maps; draft .. � • d a - i i t i. 1 - .. onifenta1, ii e:nVi pact reports and/or negative reports are , oh f71 a sand avari 1 able 1•,0 r ub the gutte. County 'Planning De artmeht,, 7 Coun�theCeiLice ri g p s y rater `Driv'�, i Oroville Califarn a. Eovironniehtal Impact Reports are also available, at college and county 1 ibt aries. BUTTE` COUNTY BOARD OF ZONING ADJUs`Th OT LAWRENCE J. LAWSON DIRECTOR OE PLANNXiiG�,,:. :.T TO BE PMISNEp IN THt CNICC ENTERPRjsL RE -ORO OiN TNURsbA1���; OCTOBER' 27, 1977. V I ' fl jl:r ! II IJ , �� 5-254'-09 ' � 46-154-13 . � 4G .:�4 " �. -172 ' p t, rtlo Hi sher'"etal ��89 18th St 8 E y Brownfield 860 Pansy 860 E St e . Obert & t4aw. 8 ase1' Wt �� . t�hico, CA 959,26,;,Chico, . CA 95926 11 BOR 25Q ,1 Durham; C'! ' 9Fi93t-1 05-254�'i 0", 46-1 Paul ix 1.,. Laciiinoi'a etah',. '48 54 1 4 Acene'ith Euyitt .-E _46-172-7 Jack Rt 3 Box Heggan Lane Chica CA 9.5926 & Shirley► Thompson 2539 5Espl;anad �`. o�esStxfZanch .CA 95942 Chico, CA 95.)26 05-254-12,26 4'6-162..0 Il , 46-1 `72-16 Phi11i p Fred & D Antohowich Veta Da Day E. 19th 796co, CA 95926 Chi � 1,757 C Street Chico, CA . 955,,? G 756 E . 20th-s- t. Ghica, CA '5926 05-254-14,15,'l6 4G 1`,;2-03,04 46-172-24.Joh! i Melba Finlay 764nB ,`19th 'St LoUi's e Silva ? 960jdEa,st 16th St,� CI aud'ine, C.amp�ael l p 0, Ci 0, 18 7 6 C h y c o ��C ;A�� >✓ .._ 95926 Chico, CA 95926 3) Chico, CA `95§27 05"2s ., � 7" Thomas & Kate A'11eh 46.162-18 i~ l Maurice & N. Da�f�is 46-18-01$02 Paul Turner 69'6 E 19th' St,, Chico; CA 95926 873 E. l6t'h Street Chico; CA 95926`` P 0 BOX 1,562, Chico, CA��\95927 05-254--,2746-162-19 46 -162 -19 E 46.. t'8 Rod & Jo Ar,n, R,van 77011 E�. 19th Sty. Buford & Donna B'Ush 783 E„ 9th -63 4a Ronald & P , iJgeger Ch-c�a, CA 96926 .Sty ?� C`►1ico,, CA 95926 1 Boxr 197 Durham, CA 95.9�s 0-254-�28 46.1y2` -f;,/,03 46 -04 ; CARD & Park Dist. 62 '� Mangrove Aver t`Iartih- & T Sahchez � X1697 E i 19th St Ro eI^ &Mir K 1 g'ard 5 Y Chino, CA95925 i Chico, CA 95926 368 5 i 19th SI', Chico, CA 95926 'k.\\ \ \\\ X 46,1 54 49 �CIAhIe1 .� K. Smith � '8, 46'-l.r2f-09 6 18,05 l l'`o,yd Buchanan � O' Rcha°rd & 'hvaruri. ,894 1'6Ih SI y �✓" Chici�, CA 95926, ���� 1 y 5 Ragho7 i q Ave, � , CNtico CA 95926 872 E r��1,9t;h (Si;'; C',hi.cu.; CA- i , 95526 � 46"154 46-172 11 ,28 fwd 45-181-06 �f10 t Che"step,?,,D- Gerieh) 880 E i 16th st, Jcmiym.aDonh'er � 783 L `t"4Ih. 5t t;' n R;. & 2V�e1 '��cCorkle 16,33 � Chi'cd, CA 95926 y i Chico; `A 959?6 ` Arcadidn Chico i CA 0592.6 ..C.y, c y 46..:754-11 Ray & A1;ta 6erf6 'ifth 46172"T2, ` 1 •f� Mar Cot iih8 ( a ... 46-18-p7;08 Couiso Silva � 876 B, st. `Ch"ice, CA 98925 796 E���, 2 tai St:� Chico CA 9592x, �� �/ S��d E, 16t -h 'St.; � Ca i c o C 1, ; 46-X54-12 _�� 46-172-13 46-1$ti09 pR i u( Rah i jt,o Caain 872. Gt: 16Ih Sti Cr}c�ss Dehney j , - 77D tic�.ir"r n.:..:.5i,i R� t0 J� ward Chico,, CA 99926Chico; .�., .. ,;1' 05� CA 926 pE'jh,'afik Rti3 Sok 10'9 y C h c o CA =I . 9 2:6 w b , 'V 41-ITTE COUNTY BOARD Or` ` ZQNl' 'rj ADJ'USTMENT' f STAFF PINIDINGS Ncrvembe x' 9, 1,977 IV., A. 1T,EM D1aMMINT!"m 4.O I1t,jCATEGORICALLY h'X1}✓�1�'C FROM ENl�rlWN�1,1�'NrA,L,s,II f>Et1? Vaxan,nce i; l i dames ll D'rljCe -- Variance t'e al loin ;) 'building 38 ft .,If Oi11 the ce(j►t-erl, ne of C Stl ect and 43 :f't., ftOln tli'e c,onterline of- 19t1i St, on, property zoned 11A -2z11, (general) located on 'the northeast '~ corner of 19th Sty C Si . , ident.i Cied 46-18 U1, Chcc< ,i The applicant states: "A Variance,, on the setl)acks as requested since only 14 :deet of width is left whon. thio present setbacks are used+ A single family residence would be virtually impossible to cbns'truct without a vor al,ICe •'1 2 ' �"N �� Sect3,or1 ..,,4 4-49 of Ordinance X750, the ComprehensiveOrdinance, stares oning Variances from the terns of that chapter s17817 be, granted ; only ���hen, because of special circ anstances applicable to the ` .ro ort � shape to' o t a ))h location p la y� �r�,_�.udin size, p' , � fi ' ] )'� , or surroundings, the strict application of t17is chapter de�pr°ivos suc}� prop erty oti> privilege, enjoyed b)) other �P�•oOp�Xty,, in, t1w 'vic'11jty anti under �.�ientxcai xonirig if "r✓1t,e Eoard Lan make these ,d itlgs, it; Would be '4app,topridte to grant: this variance � l} C� Vr " l r/ 1� It r `'�d,,'�TE COUNTY 'OARD OSS ZONrtVG ADJ> ST�iDNT /ATN. UTh5 - November 9 y 119)77 .,t� R _ 1:1 i IV. ITEM DtTERMtN13D,,TO f3E CATEGORICALLY PROM ENVIRONMOTAt A VIEW �V'AR`CAINCE` a e' D Br rV`atiance to allow a ixxl c, A. �_)J nt s, . b ` d.ing 30 ft. xom�'the centerline or C Street and <4."a ft.' from the C mt-��1 ,ve dC 19tlz $t. on property z�ohec� " Z (Genera: , �J,ocated on the noPtliodst eorner'`of 19th St. G st,i•e'et, Ifwit if as AP k6-18-01, Cliico 78 -27-2-897,, , James Bruce, 1.300 'Sa:°em`Chico, started that his lot was subs i:andard,-,w 112.5 x 414 ft.' that :,tlle Butte Cott Ay Health Department had a01Vised•M� ei h .n that the rear of the lot was need.cd 'Corach iines and that' „ t1iel 95,0 s'q f,',. h�Us �-1-Lqt, -lie. proposed to i�ui 0! Aoula be on tie front. He gadded A-ir '�e4lionse to, a c u,astion Blom- one of the board \ mombet's-yftlYat the costt�gf hooking onto a Qhico Ci�smmr Aq,ou .d o b ,,r $ 2 C10 n rr also, in res once tti;. a c( festion, Mr. Mendoz ��a� stat 0, d, tha, t there `l� - • g ," .�., , . St,reet . ,'�ex'e no knnr�n lc 'res .i;o;r the �v�.d�nin off, C yt , _ h pp nts Nome". C ons �.., . The hearing was closed and Mt. Goll,�.nst 'c , '�` ''dortt�tart;ting that jrre az;o .tvr�rk°irig ' wlith aft' area with a liist.oty, of poor,, lot" osig, ) made a 1�,6tibn to approve thisI vatianee because '%f the s1Lzeand c ha r.. p of this pr6p rtv u�t I cannot.)be � l ized fully without g��ant� -� �n`g sic}� �r�rtc:.d a�i5 %otton was seconded. by Mf .,-'Ap.p.1,man (� �,AYtii Appleman; C611in.s and 4 hairma•n Camdiftind, AB8ENT: NO, bile, 13 r, a, Motion 0avriedt �.. F.y `l t :\ 0, f S'i . '.6 0 ell I( IJdVembex 10''1977 1 Mr." James D. BtUC (300 Salem :•, �� C h ii o, Ca 9502 6. <.� Re,,, Vara,aacegon,AP 44�� !8,, ill cy "« Dea.r lair . Rrute ,r At their regular me0ting on November 9, 19'77 the Board � r1 0 ,�I ;' Adj u.>tmeI� t approved yoi91 application Por a r 11e to alx opt a biido��th� the cehal�t �' C1a�1 reet and-43, ft, ai'ie p 7 center' Street, _ r� on 'the nort h0As�t-�corn;er of 1901 �St � " St, i n chito , -'` j there are "no" appedis'-,duting the 8-d'd)r ap`poal perib6, Four `Var1.a-ncerwill be considered gxanteri after Nb,'.foiibot �� � 23 r 1977 � tete date of the official appro�tal of the l mlrnutes for the meeting of the Board ori Novembor, 9. � 5houlr� you have ari}.tt4stions concexiAng this mater; please -feel frd-d to,, contact our office, I r. '/ � :`La"tv'rence d`► Batvbon .; Director of P l a n'n ing h YFi,a , r. ;.r•• l) �, � r- a t,} , 0„ N0TIt+F Op Di."U,**RMINATION T it ti E,,"r TO: Ci ;Secretary For Resources 14i6 Ninth st,, Room 1.311, 11978 S q c. r,'i itt Q n,t o , CA, 9581.41 CLAW A. NELSON, Cau n !irk -� 4 +�' CI q,t Bybnpu}y County e (;Pild) County of tLiTTk� l"J10m - 1859 E3—rr7�,�'tr�e ----_� lard gendy)_� 00 n , of 13tt•te. � �n Z3rovi.LZe,`Zar3_..� 1KK ...ronmentja v w monis 65 . URThC ' c F l int o:c-- �ti:c0 of net0rm51ia.t io71, i..1 Cu+ Section 21108 or X115`2 0;6{ the 1)ub1i't sourr �{t;odc a ' J PT0J0Ct 1a �._:.».,.�M 1�.7% 11 (i. (I at �1. i_ CLF .�. A� 4 6 -18 01 J,�rt1� (�, 11^ure; State Clea zri �otise �'��ml�r Ji stt mit Lori to SvaL Clea��rthat e ontact (4,-) ex , T01 Ci 1 otic Nuirheh M ------ P si : e c. t, n ;9 5 t :1^e e t r h i i c r oo. ..._ .... _ ._. ..__..;.: ..�..:._ _.. Vat,1,ahce' ati se'tbcick 6f: propost=d''d ,eIIing, 1ti This is to adv iso that the Go tnt ,off I3u bba woBcl i d A �a. .. f .i it t mc* h s 11,15 made tho ,v11.otv:in determ'a.natzons tc a'rdi1ithe abdo8eribed I j,ect tro w << 1, The project has 'been�approved by the Lcad Ag,ol cy`: CD: disaj pro ?pori �> 2, The prof eet Cj «i11 halm a 5?.Pnifica t orroct ott ti fe e�y ra roy�me t r ►�t1l.Itot y= C�1 An >Jrtvi-i`onmontal `mpact was- propa-tod for th 418:1 project' pursuant to the p`rovisiotis0r "I"O'A,� 11W- WAS i��t"nr10,d a�!, 14o,.' -q'Ltirert by 8ectioh LSCS (g'y`S !it 4,��.ilbl�t�Ia Ac1n��ttistrati. �e bode, ! 7 A Neggt i Vj Docl av,,Atioti was ptopaj,od for thi , 1pvo10tt 1�ttrsi n11t to thy: ptovi8ion. of C.h; ode 0A0 VILLA CAL,IFORNIA " �A �- t�ER L CLAIM CLAWANT: ADCjF2Es Sa3 em ala CITY & STATE: ._QOL ` S2J±n I ( �5 — IMPORTANT. SEE IN5TRUItTIONS 15 DATE'OF CLAIM: _'�"� "IZ� . f,d' ON REVERSE ME SUBMIT CLAIM TO DEPARTMEN`, RECEIVING GOODS OR SERVICES FULLY TO AVOID � DELAY) AMOUNTY �t DATE OESCRIP`1�ION OP CLAIM.; (bI=SCRIBE , '1--1q-79 Refund o U'se Permit tees �n �� 54-09-23 (p�o��ci _.. .�.� ... m. • Categori`cal7.y Ex�� p�,._ �"s�sm ,B ierital Review process. 100 OU k' , f ,4{ r , 17" n . , •.e....�,,.,,.�,. -..=ate. ... 1_.J�-,�=_.F-i:. _ .. -... .,.. ,.,...,.......�:,, .. �r x , I f ^00 TOTAL II the tuidcti+igheti/ dbglpi•e Under pattglty bf 0E'H'uty that tbs nc,rvlgost dt grtlolee L'Illi hod hfiVb boor ci(ahxicd dt dell'vetcdl ohd thnt this tlblm (tl ttUe bnd hgrrC ct O btBtcdl it . �b4•x.•'!•," r 12il.l,xF �I1fit9 ut la.l' lu 111 I I ........... ir..eiu:t4:.r11allx+lll:lcxl {' 1 e,t '• int ut, t,} �"� y litld this4 ,.......... dqy $itluottlta qt G 4lN1Nht l.rjhe uiidorei�icdt J,ereby d4ttlt5 thiih W the bbit. at thY knnNlledg�; the oovie i gF itFtldlbtl irpcglClld bbgve lip've beLti 136 f? oil de- 1tVbred 'ttticl thiit there, It it I,ludgitt Ahti uhrlgt'Mtih of 5ticcltl Uabtd Apptgt`f (Chdekhttb) tgr�thz shhi'x et `t nl(1 I bIlt ' thited Wilt llfillw�r.^I.111111.'lelr.+1 1111 dti'$° qt yl yT i�.. t.Z�S{�x��xx>r i 1�,4, � bt xµ�J11�1Y,x .� C- ' .4u 'I � �S `Ir„kl} r'xh'.dxU ho ...... �a qep 4 1 t �y �q) �j y 1+ l Cbdk �.:iva.4 .•o in.rl . , •.•tSd� "4 1,.1. x�AT ANIJ Lw l�.dbl �I:��..i.. Iu1 .1.uiR1 1 Illi. , 111 11 ,SC'.1 C�Nb. , 1 IN 4111 1 Ie, ( 1) NOT WRITE BELOW TH1� LINE ` FAUDITOR S USS ONL p b r, sUlil CLAIM INvolc� , INvd1cE I GIi05$ f V�NpJp:' Nos NO, 15�: (=NCUMl1/ �^ ,. •' , I'RJI fyA1 . '., ... AMtlUNT,. I;Ug.d15T: p' 13J1 � Cb6� �d: sU�l d D t , Y , Is i • I = tr U u �