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Action Requested By: _: <br />Name of Property~Owner / ~ ~.S <br />Phone (h) --~57 - t~ ~ - ~~?~-~ /a~~H) (w) _ ,:s7- 4' ~`~ - ~~,~ i r' ~~ ;~, <br />Address of Property Owner ~~~7 5~-~-i/,i,~ ,,~,~ rte, <br />Name of Applicant (if different) ~v~~s . ~,~ ,~~, r-~ _ ~,~~ ~~~ . <br />Address. Phone ~ ~ • <br />Property Involved: <br />Address ~r ~ ~ S~~~t~~~ ~,~', . <br />Legal Description `' r . <br />Property Identification Number (PIN) ~-~,~:~~--~~-~,~~~ ~_~~_~~ <br />% / ~c~ _ <br />Present Use of Property (check one): <br />^ Single Family Dwelling ~ Business/Commercial. <br />• ^ Duplex/Two Family Dwelling ^ Government/Institutional :- ' <br />^ Multi Family Complex ~ ^ Vacant Land . ~ • <br />Action Requested; (NON-REFUNDABLE): <br />^ Variance ($100.00) ^ Lot Split ($250.00) . , <br />^ Conditional Use Permit ($165.00) ^ Site Plan Review ($100.00) ~ • <br />^ Rezoning ($.500:00) ~ Other (Please Specify ~ • <br />~~ ~~ ~ ~~ <br />Brief Summary of Request .(applicant may submit letter to Planning Commission with. <br />details of re(quest): ~ ^- <br />/ ~,.~5 / s~ ~'i.~4 (-i'L~:° /rl~fc' ~i. c.~C~Gf~C> G %~~c`l< 7~ C~~lJ~.,.2. r'/.?3n f5't- , <br />1 certify that all statements on this application are true and orrec <br />~~ ,%' <br />Signafureiof Properly Owner (regrui;~ed) Signature of Applicant( applicable) <br />•f <br />S:IFORMSIBLDG PERMIT RPTG FORMSIPLANNING APPLtCATION.doc <br />. .3,~ o~ 3 <br />