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<br />�ADC�RES� � :. /� ol� �=M7:�TC�1�r�ir��:-=�'lJn/n/ETOnlK�4.; .M� :_�.�'34�� ,_ ._.��� �
<br />:�.. ` . Sfreetc ,4ddress, C�iy Stafe, and Zip Cade 4�
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<br />(nteeest in Proper�y (check,apprapna#� box � � -
<br />- _ _ C� ` Owner af Praperty } ' - - - ' � -
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<br />� :._ _ :: ❑ ._ ,. .Cantract for Deed Owner _ : _.. �_. :_. . _�r :. . ..
<br />..__ .. . -,_ �' .� ,�. , O�efdtot, .` Pro}e�r4�- A�4a..�.q�s� .
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<br />� ❑ __�: �.:.ASreement ta Purchase -. : ... . , . .. �= . _ - - _ .
<br />.. ��� _ . .::"' : Q� :: Other {explain) c���e.�er �b�:: ���1� 4�vFt'cN,�SE',2 , - ._� ....
<br />Qacumentary evidenca of appUcan4 s in4erast in th� `ro e t � - ° �- .
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<br />:� r ,�L�� � � � F p p rty msy be requued befora final Ctty ac4ion of this requesL N''` "
<br />Y} 1G1� [l� 1 s �v.�..^�°eAP•x C5i�r4 w{� .�!laP _ � $ . '? . -F,� .. � � a��•4 � M5- .
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<br />- ,- Address/Ceneral Loca�i�n o��ac� ,��- °zo�s°�-�v_�r�e �.��/ ��wau`Ai�s1l��.�v�� �i�: v:
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<br />. Legal Descript�on,;or .Property lder�fification__ Number o�'�,� o-�y3 .�c� �� e o�, �.�� µ,,;. :�
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<br />_ _Legat Owner__ Name/Address ro �,aw �,� � . �«.c ,�� � �,�a � � a+ rv G ����:a`^ _ -
<br />. . rvE�s t� c i 4� o r �� . a� � n� n� �.'i n N � ,� ns� � : Ss °3 „� . -. - . . ., _ .
<br />- � . ,;�.., � • ; -
<br />. . Present Use (check appropriate bax} ;
<br />- ; _ _ • [] ;...Undevefoped/Vacant _ - - .
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<br />- � � ❑ �° Singfe Famiiy Dwelling �::. , r r �
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<br />, - ❑ ` -Duplex/Two Family Dwreilin �-� : � r� .�.- U..��` � � '
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<br />- _ E ` l .,� , _ ❑ "inctustriai, Establishment � -' ' , a.. � ' � �- ;1 �-
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<br />; Property Ciassficatron � ' _'-�� ,� �_`. _ - -
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<br />. - -. - . _ ' j��Abstract - � .. _ iorrens - -- - -- - -� -- - ... ._ -
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<br />' REQUEST: s�� ��r`4���_ .._- . . .
<br />�Please note: Applicant may be responsible for acidits�na! fees assaciaYed with ;he review of this requesL
<br />I HEREBY DECLAR� iHAi iFIE ABOVE STATE1VfENT ARE TF�U�. 7Y.�2�.�. � ����,
<br />Signafiur�
<br />����-����*����**,.�*�������*���*��*��**���*A*��**�*���**���t*��R�*�*���*��*****��*�����*Y����
<br />Rezarnng
<br />Variance - - -
<br />C ndit�o i Usa permit
<br />ode A e -
<br />Develop./Sfte Plan Review
<br />Minor Subdivision --
<br />�rlajar Subdivision
<br />Comp. Plan Amendmenr
<br />Wetland Alteration Permit
<br />Wetland Buffer Permii
<br />Pfanning Sign
<br />PtJ D -
<br />PUD Amendment
<br />5200/acre, minirrrum 52�0, maxrmum $1.000
<br />R-t to R-2 - S75, all others 5200
<br />R-1 ta R-2 -�75, al! others S20Q
<br />$7S -:=
<br />S10Q/aeee, minirr�urra i00, ma�cimuers 5500
<br />St50 � . � . . .
<br />�2Sfl plus 5250 depasit ' " - - .,
<br />�200 �
<br />�SO pfus deposit determined by Staff
<br />�10
<br />350
<br />w350 �
<br />$150
<br />Paflc Fund Dedication Fee
<br />- Date Faid
<br />Fiecei4t Number
<br />To;al Pees Paid
<br />date Paid
<br />ReceipY Nurnber
<br />Additional Fee Paid
<br />Date Patd
<br />Fleceip4 Number
<br />[�ate of fina! acfiort
<br />APFROVE
<br />� � � � 0
<br />- S � _
<br />/,, • '� ❑ DEiVf�D j] TABLD �
<br />Date (.� ' � � Pianning Case No. � / - � � Admin. Acraunt (Vo. _/r7 %
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