HomeMy WebLinkAboutPermit Permanent Sign SN-13-60 - PILLSBURY MANOR SOUTHPermit Number SN- -
City of South Burlington, Vermont
Application for Permanent Sign Permit
1) OWNER OF RECORD (Name as shown on deed, mailing address, phone and fax #)
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VT o 5q,03
3) SIGN LOCATION (include business name, address, & phone #):
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4) TAX PARCEL ID # (can be obtained at Assessor's Office) IK10 D 153��
5) SIGN ERECTOR (Name, mailing address, phone and fax #):
7) DATE OF ERECTION A S s,-kdea1 Q-1CiSs3 v-�-t iTi c, V�¢..w
8) SIGN DATA
WALL SIGNS (list size in sq. ft., illumination, & type
FREE-STANDING SIGN
such as panel or cut-out letter)
1
SIZE (in sq. ft.): J 5
2.
OVERALL BEIGHTN /
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SIGNABLE WALL AREA (in sq. ft.):
TYPE OF ILLUMINATION:
tib"�y �1 h15 1
N v 1 n: A scaled rendering of each proposed sign must be submitted-i3lustrYting the color Kf the sign and
noting the dimensions of each sign.
9) DATE OF DESIGN REVIEW APPROVAL (if applicable):
10) Applicant Signature: (i��� Date: D 1
11) Signature of Land/Building Owner: Date: /D
Do not write below this line
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Fee: AD Dlication: Rejected proved
Code Officer Signature: Date: w dlll�
Pillsbury
Manor South
A Pillsbury Senior Community
v -,
Pillsbury Manor
Addendum to
Notice of Privacy Practices
This document is an accompaniment and addendum to our Notice of Privacy practices. It
is intended to inform all residents of Pillsbury Manor, both Residential Care and
Independent, exactly how Pillsbury Manor will maintain your privacy regarding general
inquiries.
Pillsbury Manor has a directory listing all of its residents. As a convenience to
friends, relatives, and people having business relationships with you, we will
respond to inquiries about your residency by being truthful and forthright. If
someone calls and asks if you are a resident here, we will say "yes" if, indeed
you are. If they request to speak with you, we will generally give your phone
number as a convenience.
Yes I would like to be included in your directory and would like you to
inform people that I am a resident of this facility, what my
room/apartment # is, and, if they ask, you may give out my phone
number.
No, I do not want to be included in your directory. If anyone calls for me
you should simply say that I am not listed in your directory.
2. If you are out of the facility, and you are listed in our directory, we will tell
people that you are away and when we expect you to return. If you are in the
hospital, at a rehabilitation facility or somewhere else receiving medical
attention, we will say where you are, but offer no further information, and
direct inquiries to the family.
Yes, I would like people calling about me to be kept informed regarding my
whereabouts and general condition.
I am listed in your directory, but please give out no further information.
Name
Facility / Apartment or Room #
Signature