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If there are any additional facts regarding the Premises and its proposed use which would be <br /> material consideration,please include that information: <br /> --- <br /> Signature .of Authorized Person / " / �� <br /> Typed or Printed Name of Signatory: A'?,e M =Z� <br /> Title of Signatory: PestiA-1/1ue:-. 4W--&>c-z�Z) cruet tai-=e ,;mate: 7 - 2 -3 , 2005 <br /> City or Other Governmental Agency: / 7-7 o f= >/�:x'uc= <br /> 3407/1059:01/25/05 — 3 - <br />