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CITY OF LA PORTE RECEIVED <br />VONG BOARD OF ADJUSTMEI& <br />SPECIAL EXCEPTION REQUEST �'�� 10GM <br />Application No.: <br />OFFICE USE ONLY: Fee: $150.00 Date Received: -- <br />Receipt No.: rr <br />Note: This Fee is Non -Refundable Regardless of the Board's Decision <br />kl <br />Applicant: 4/ Je <br />Name <br />/.�01de Gb PH: 2,? y7 ) <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 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 'c%� t� �� J, <br />Street Address <br />8 /o c K 4• L o4 3 3 2 -- <br />Legal Description <br />() Site Plan () Minor Development Site Plan <br />() Major Development Site Plan QQ 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 />V' 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 act on the Owner's behalf. <br />3 -- 2 z o V <br />Date Applicant's Signature <br />Office Use Only <br />Site Plan and Authorization (if applicable) attached? Yes (b No () <br />Date transmitted to the Board of Adjustments: <br />Meeting Date: o� ! (� 7 Applicant Notified of Date: <br />Board's Decision: Approved () Denied () <br />Notice of Boards Decision mailed to Applicant/Owner: _ <br />