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CITY OF LA PORTE <br />ZOPSG BOARD OF ADJUSTME4 <br />SPECIAL EXCEPTION REQUEST <br />Application No.: 00,2 <br />OFFICE USE ONLY: Fee: $150.00 Date Received: <br />Receipt No.: <br />Note: This Fee is Non -Refundable Regardless of the Board's Decision <br />Applicant: <br />Name <br />� dress <br />I am the owner of the herein described property. I have authorized <br />to act on my behalf in this matter. . <br />PH: <br />Owner*: Powa it-m Vm! r� s --r-dy �. <br />` Nam <br />d) <br />--/V -7 9EA PH: <br />Address <br />I am requesting a Special Exception 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 <br />Street Address e� <br />/A-s w 1. 3 Z. - 510� �(o i S a J- e—A- T eRTC- <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 Authorization to Wd I <br />on the Owner's behalf. <br />0 <br />Office Use Oily 1 / <br />Site Plan and Authorization (if applicable) attached? Yes () No () . <br />Date transmitted to the Board of Adjustments: <br />Meeting Date: <br />Board's Decision: Approved () <br />Applicant Notified of Date: <br />Denied () <br />Notice of Boards Decision mailed to Applicant/Owner: <br />