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Too'd IVI-01 <br />CITY OF LA PORTE <br />V"—k "Aiii&i <br />AppUatlon No.. <br />oFF_jcy,AF ohLY. Fee., 1 e ate eoeived <br />Receipt No., <br />Nter This Foe is Non - <br />Refundable Regardless of the Board's Decision <br />, <br />Addx-m <br />Site PISS Minor Development Site Plan <br />Major Develtipment Site Plan General 111nu <br />........... <br />A Site pinji of the property is attnchecL &Lio, Y have Fisted the inforn=tion reque-stod belvo, on thA <br />fol I owl ng p 2-W&s of thIs form. <br />a) All facts conceraing the xnatter that has led up to this requesL <br />b) The type of relief I am Fenng (setbacks, lot coverage, efe,), <br />c) The 5roupa upo)u which I am makiRg,ffiIs request. <br />If applicant is NOT the owner, he M2A provide Ckttthoyi=don to act OUt Owner's behalf <br />Date <br />0frice Use Only <br />sale plja pftd ,kutlior"tlon (itapplicable) uttpch6d? Yes () No <br />I)ate transmitted to the Board of Adjustmeutaag <br />Meeting, Date: AppHcant NotiPjed of Date - <br />Notice to sarroundIng property owners- Date. <br />Board's Dt,-cisioyi: Approved () Denied <br />Natim of YWftrd& DVCiS10T) Ulftiled to APPUMAt/0"cr: <br />TOO/T'00'cl M: T T T T 0 3 - 7, T -;DE,'-7 <br />