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Htr#F1E t frila <br />TAa' <br />3t*Lci/(h/f # oW&47!,,\ <br />to{ate: <br />to <br />Dcscribc the s an ls <br />Date wo* will be complctcd:(m,/e/yrW) <br />Section 3: Signaorre <br />Take notice that an epplicatioa for ao cxtcosion constitutes ao admission thet the Noticc ofVioletioos aad <br />Order to Corrcct is Ecnrlly rod corcct and that thc violatioo docs or did "*i.c lo addition, <br />the epplication for en cxtcasioo cons e veivcr of thc 'ight to appcal as to thc violation fot which aa <br />extcosioa is epplicd" <br />Ownet/Appliceat Signrtrrc <br />Mfikadt!aiboripd oJrk Pnpdr. <br />I <br />, <br />01. <br />3 <br />Date: <br />NO <br />U s ( eor <br />rs 5 <br />filr _KJ <br />Co t4//*2 uil[l AP <br />&,otApproved <br />Inspector: <br />Iaitial <br />Superisoc <br />1 qL^l <br />ob <br />Subseoucnt (numbcr rcouest) <br />Denied <br />This request is thc: <br />This request is:Rcccivcd:r/ e. <br />Office Use Only <br />P^*2 <br />I <br />tr <br />tr