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CITY OF LA PORTE <br />' 2 'CONG BOARD OF ADJUSTME• <br />SP <br />ECIAL EXCEPTION REQUEST <br />Application No.: — <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 APR -1 .2004 <br />�. -�� <br />PH: 21. <br />lam the owner of the herein described pr er . I authorizedJeLi <br />to act on my beha in this matter. <br />Owner*:9~� , <br />Name <br />Address <br />I am requesting a Special Exception to Sect. I ; " of the City Zoning regulations Chapter 106 <br />of the Code of Ordinance. <br />I am requestiIAAI- <br />this Special Exception for property located at = � r 19 91JA&I <br />I r1T' 7116 J.4 - 2 A.. _ 11_ _ I" .. // r Street Address <br />r <br />Site Plan <br />() Major Development Site Plan <br />.1 LeRal Des <br />() Minor Development Site Plan <br />() General Plan <br />A Site Plan of the property is attached. Also, I have listed the in ration requested below on the <br />following pages of this form. <br />a) All facts concerning the matter that has led up t his r que <br />b) The type of relief I am seeking (setbacks, lot co erage et '•` <br />c) The grounds upon which I am making this re st. <br />* If applicant is NOT the owner, he must provide Autho i fl on/the Own is eh <br />Date L / Applicant' Signatur <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: Applicant Notified of Date: <br />Board's Decision: Approved () Denied () <br />Notice of Boards Decision mailed to Applicant/Owner: <br />4./1 <br />