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CITY OF Lk PORTE <br />ZONTINTG BOARD OF A-DJUSTM-ENT <br />Application R�0-� <br />OFFICE usc, ONLY.'.. Fee: L5_0,00 Date <br />Received: c - <br />Receipt No.: <br />Note: This Fee is Non —Refundable Regardless of the Board's Decision <br />Applicant: 47 <br />Name <br />Address Phone <br />I am the owner of the herein described property. I have authorized <br />to act on my behalf in this matter. <br />e <br />Owner*, <br />Name <br />7 �SI I �14en <br />-Address Phone <br />I am requesting a variance to Sect. of the city Zoning regnlations Chapter 106 of the <br />Code of Ordinance. ----I (A y (� n S-� <br />I am raqUCSt1Dg this variance for property located at <br />St eet Address <br />Legal Description <br />Site Plan Minor Development Site Plan <br />M . ajor Development Site Plan General Plan <br />A Site Plan of the property is attached. Also, I liave listed the information requested beloiv on the <br />following pages of this form. <br />a) All facts concerniDg the matter that has led up to this request. <br />b) The type of relief I am seeking (setbacks, lot coverage, etc.). <br />c) The grounds upon which I am malting this request. <br />If applicant is NOT the owner, he must provide Authorization to act on the Owner's behalf, <br />J - <br />Date Applicant's �Si2n�atUre <br />Office Use Only <br />Site Plan and Authorization (if applicable) attached? Yes () No <br />Date transmitted to the Board of Adjustments: <br />Meeting Date: <br />Applicant Notified of Date: <br />Notice to surrounding property oivners- Date' <br />Board's Decision: Approved () Denied ( ) <br />Notice of Boards Decision mailed to Appllcant/OWner: - <br />