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This Petition, Waiver and Agreement may be executed in one or more counterparts, each <br /> <br />of which shall be deemed the original. <br /> <br /> Dated this -~ day of ,_~cA~fx~._ <br /> <br />OWNER(S) (signature required) <br /> <br /> Date <br /> <br />3. 6/W <br /> <br /> Property <br />_fOwner Print Owner Name Description <br /> <br />10. <br /> <br />11. <br /> <br />12. <br /> <br />Date received by City: <br /> <br />By: <br /> <br />Its: <br /> <br /> <br />