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CITY OF LA PORTE <br />ZONING BOARD OF ADJUSTMENT <br />Application No.: <br />OFFICE USE ONLY: Fee: $150.00 Date Received: <br />Receipt No.: <br />Note: This Fee is No)i-Refundable Regardless of the Board's Decision <br />Applicant: <br />Na me <br />IIIJ11.) DO <br />Address Phone <br />I 2m the owner of the herein described property. I have authorized <br />to act on my behalf in this matter. <br />Owner*: � l <br />Name <br />Address Phone <br />I am requesting a variance to Sect. I — of the City Zoning regulations Chapter 106 of the <br />Code of Ordinance. % <br />I am requesting this variance for property located at <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 />Date <br />Office Use Only <br />Site Pleas and Authorization (if applicable) attached? Yes () No <br />Date transmitted to the Board of Adjustments: <br />Meeting Date: <br />Applicant Notified of Date: <br />Notice to surrounding property owners- Date: <br />licant's <br />Board's Decision: Approved ( ) Denied () <br />Notice of Boards Decision mailed to Applicant/Owner: - <br />