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ZOACITY OF LA PORTE <br />G BOARD OF ADJUSTMEIS <br />SPECIAL. EXCEPTION REQUEST <br />Application No.:. ^UD <br />OFFICE USE`ONLY: Fee: $150.00 . Date Received: -o <br />Receipt No.: <br />Note: This Fee is. Non -Refundable Regardless of the Board's Decision <br />Applicant: . • f <br />Name.. <br />Address <br />I am the owner of the herein described property. I have authorized <br />to act.on my be..haalf-_in this matter: <br />Owner*: �P �('Clt C�tn {fYl�� �� <br />Name, <br />(lf1_C PH: <br />Address <br />I am requesting a Special Exception to Sectof the City Zoning regulations Chapter. 106 <br />of the Code of Ordinance. (� - n <br />I am requesting this Special Exception for property located at �3 �IYY <br />q. <br />Street ddress <br />�Pn• J-. 'h'I Lrk 'rn I <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 />follow_ ing .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 caner, he must provide Authorization to a t on the Owner's behalf. <br />D e .. 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 - Applicant Notified of Date: <br />Board's Decision:. Approved () -Denied ( ) <br />Notice of Boards Decision mailed to Applicant/Owner: <br />