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pLANNINo npf'llLlJlilll <br />Date <br />L t s phone <br />nrruCAnt: na,Me_1w% _ ^le!Y-- <br />�,,.:�r r <br />address <br />Interest In property appropriate LOA) <br />owner of record <br />[] le -ev, uprlatur, wane9`'r <br />0 contrd.-t fur deed Owner Ct uglnelnent to purchase <br />p other (explain) -�__.�.�— <br />------ <br />- �� <br />_ -- n!Jly rviJenU Of ,y(licam 's iuterrst In the property "^'y be <br />Duculne <br />f L'yulred Lrl,l,r filial lily Jtl tun po Ihi, request. <br />pROpLATY: dddress/4vnvrJl lolatl,m <br />legal owner nanr/addrr,s <br />present use (cheek Jpprupiirta box) <br />(3 un JtvelupeJ <br />O bu,iness establislunent <br />51n91t f.nnily dwelling O industrial establishment <br />Q duplrn Jwelling Q Jpdrtment, <br />0 other (uxpldln)—_-____------------- <br />ILfVUEST: (explain) ._--Mee'lA.._--SKL1-�>!ai.'-' <br />1 hereby de,IJre lhdt the above statvmenls are tluc•-�iignatcre <br />FOR OFFID USE ONLY: <br />BASE FCCV <br />subdlvislun, naJvr <br />%ubdivieinn, elln.,r (57S) �l-_- <br />rezoning (`5`•Ol __ __ _ <br />cooditialal use mo) <br />Owl)coe aP0)� 05 <br />code appeal --- <br />s„h <br />*Base fees In parcuthv%is are nun- <br />►e(uudable. <br />Park (unJ <br />data 1.4.d <br />AUCITICNaL PECS <br />Ir,q.purtionxe•nt <br />Public 'x'aring uat.ccs _ <br />consultirnt reviews <br />n�is�, l lanrlm� _ <br />subtotal -?' <br />TOTAL FELS/'/` <br />date paid <br />receipt <br />