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CITY OF LA PORTS <br />ZOOG BOARD OF ADNSTMEP• <br />SPECIAL EXCEPTION REQUEST <br />Application No.: 00 3 <br />OFFICE USE ONLY: Fee: $150.00 Date Received: ! - S -oil <br />Receipt No.: <br />Note: This Feels Non -Refundable Regardless of the Board's Decision <br />Applicant: /9 `fury #?V51 A✓.G tOAA rxf c-Y2 S <br />Name <br />�U QO x 95T J-�Z. .79 <br />6 <br />2G. PH:-�I <br />Address <br />I am the owner of the herein described property. I have authorized <br />to act on my behalf in this matter. <br />Owner*: <br />Name <br />PH: <br />Address <br />I am requesting a Special'Eaception to Sect: of the City Zoning regulations Chapter 106 <br />of the Code of Ordinance. <br />I am requesting this Special. Exception for property located at J ill/ S. f <br />Street Address <br />k 4- (-7,WZ W <br />Legal Description <br />Site Plan () Minor Development Site Plan <br />() Major Development Site Plan () General Plan <br />A Site Plan of the property is attached. Also, I have listed the information requested below on the <br />following pages of this form. <br />a) All facts concerning 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 making this request., <br />* If applicant_ is NOT the owner, he must provide Authorizatio o act on the Owner's behalf. <br />Office <br />Site Plan and Authorization (if applicable) attached? Yes () No () <br />Date transmitted to the Board of Adjustments: <br />Meeting Date: Applicant Notified of Date: <br />Board's Decision: Approved () - Denied () <br />Notice of Boards Decision mailed .to Applicant/Owner: <br />