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Attachment C <br />By signing, the undersigned certifies that he /she has read and understood the submittal requirements <br />outlined, and that he /she understands that omission of any listed item may cause delay in processing the <br />application. I (We), the undersigned, acknowledge that the information supplied in this application is <br />complete and accurate to the best of my (our) knowledge. <br />PROPERTY OWNER OF TAX LOT: 1 - 4 ' 0+ - Z 11 A 40 3 0 1 <br />Name (print): EM t LNj ?,C— <br />Address: I M Email: CMI h L449,0� kDO • Cem <br />City /State /Zip: Phone: Fax: <br />Sign ature: <br />PROPERTY OWNER OF TAX LOT: <br />Name (print): N / <br />Address: <br />City /State /Zip: <br />Email: <br />Phone: Fax: <br />Signature: <br />PROPERTY OWNER OF TAX LOT: <br />Name (print): R /A <br />Address: Email: <br />City /State /Zip: Phone: Fax: <br />Signature: <br />SURVEYOR: <br />Name (print): J D S& g A . OAK -h <br />Company /Organization: �p,dt�o EJV INC�/Zl��6 SI�Ra/�EY /� 1146 <br />Address: j�p � 0� <br />2� , C (O <br />� D R q <br />1402 5Z <br />D �i l <br />— S� <br />City /State /Zip: <br />C- A,(pr-tj G� <br />6(Z q7402- <br />Phone: 4u- <br />4JZ5 <br />5 41-4 1 5 - - 5 <br />E -mail: <br />Signature: Sur-, AT TAr et? <br />Annexation Last Revised 2/2008 Page 3 of 4 <br />