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OR <br /> Development of Regional Impact (DRI) :..r. god Eommission <br /> Referral Form <br /> Please attach a copy of the original municipal development permit application or site plan <br /> review. subdivision. or other application showing the date on which it was received by the <br /> Municipal Agency. Receipt of this Information via the U.S. Mall or delivered in person to the <br /> Cape Cod Commission constitutes a referral for purposes of Chapter 716 of the Acts of 1989. as <br /> amended. <br /> Referred by: <br /> Town <br /> cy <br /> 111 4 <br /> Official <br /> Mandatory referral <br /> l <br /> Discretionary referral <br /> Limited Discretionary referral (please see the back of this form) <br /> Project Name ]r? IQ SS I (� IJ�MUn►� bAt �c�l.r,r <br /> Project Pro on nt Nam QDuCO t' <br /> Address hil f AIAL <br /> Telephone <br /> Brief description of the project including, where applicable. gross floor area. <br /> lots, units, acre and specificises: 1� C <br /> K-066AX I �2 <br /> I <br /> j A J C 4C1 Ud,'e 'fC'r.� ' <br /> ;�r i a IZ <br /> rA . <br /> Project location: <br /> 6c oa in T WJ <br /> List municipal agency(ies) before which a municipal development permit is <br /> pending: <br /> Q <br /> Print Name*of Authorized 3Signature datef <br /> Referring Representative <br /> Forward to: <br /> Cape Cod Commission <br /> 3225 Main Street <br /> Barnstable, Massachusetts 02630 <br />