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CITY OF LA PORTE <br />ZOrW BOARD OF ADJUSTMENT <br />SPECIAL EXCEPTION REQUEST <br />Application No.: (5 <br />OFFICE USE ONLY: Fee: $150:00 Date Received: 7-2.m? 0 <br />Receipt No.: i 7/ tile <br />Note: This Fee is Non -Refundable Regardless of the Board's Decision <br />,Applicant: <br />Name . <br />//92,3 �o '"C%l t /'e ft PH: r77 .S :$3/ <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 />//92 3 S�vr S �iGG�c� PH: 532 —572 <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 /yo�3 �c7t&x.14vi/ <br />Street Address <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 act on the Owner's behalf. <br />r <br />Date v11 Applicant's Signature <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: If — Z L' Applicant Notified of Date:. 7^24 -eq <br />Board's Decision: Approved () Denied ( ) <br />Notice of Boards Decision mailed to ApplicantJOwner: <br />