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Date <br />o <br />, <br />�If <br />luir�,V. II h- <br />IIll Ill1 1' 1 <br />Zoning District <br />Print <br />Property Address�-- <br />Map:_ .._ ._ Parcel: <br />Petitioner ._ <br />... _ _w w l "�`'._ Phone .. w._.... . c <br />Email WID .w ww.._......... ._........... - ...- C� S CD�i <br />' _ . .....kw' .w _ ,....` .......� ....m....... www_........ �......... Phone ;7 7 .. - V 0 7 - Z / <br />Owner's Name 41 7 b <br />ZBA Original Docket Number [ 4ft )aI . <br />Project is a: P I Deck Addition House U Other <br />Proposed Modification <br />raoAJ-r" i <br />Owner's Signature or letter <br />Petitioner's Signature <br />Mail certified copy of Decision to: Z $ ._..� C200 v-, <br />................ . _ . _ .._ ................. <br />tt Scheduled Date <br />Rev 6105115 <br />TOWN CLERK <br />DATE STAMP <br />�. x ape-I4 <br />