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CITE' OF LA PORTE <br />ZONING BOARD OF ADJUSTMENT <br />SPECIAL EXCEPTION REQUEST <br />Application No.: <br />OFFICE USE ONLY: Fee: $1.50.00 Date Received; <br />Receipt No.: <br />Note: This Fee is Non -Refundable Regardless of the Board's Decision <br />oe <br />Applicant: �{) J %�'� t'�I pis l• pk,c�. <br />Name �' <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 />Ownez"�: <br />Name j <br />Address <br />I am requesting a Special Exception to Sect. of the City Zoning regulations!! Chapter 106 <br />of the Code of Ordinance. r IV ';�� <br />I am requesting this Special Exception for property located at <br />j Street A dress �r) <br />Legal Description <br />:e Plan () Minor Development Site Plan <br />ajor 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 inatter that has led up to this request. <br />b) -The type of relief I am seeldng (setbacks, lot coverage, etc.). <br />c) The grounds upon which I am making this request. <br />If applicant is NOT the caner, lie must provide Authorization to/act on the Owner's beliq <br />Date 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: <br />Applicant Notified of Date; <br />Board's Decision: Approved () Denied () <br />Notice of Boards Decision mailed to Applicant/Owner: - <br />