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PLANNING AI'PIMATIOU <br />11,111! _s WAf..: . <br />phone , rJ,..d6/•d <br />APPLICANT: name <br />address —? v �.1J flL ai✓.—.r4_— ------ ----- — <br />Interest In property (check appropriate box): <br />11Ktrwner of record rU le•+see, operator, manager <br />D contract for deed owner 1.1 agreement to purchase <br />ri other (explain) -------_---__---_ ----- <br />nocumentary evidence of applicant's inlerest In the property may be <br />required before final city action on this rrquest. <br />PROPERTY: address/general locationiC-- <br />7 <br />legal owner: name/address <br />present use (check appropriate box): <br />0 undeveloped t7 business establishment <br />y� stogie family dwelling U Industrial establishment <br />/[] duplex dwelling L7 aparunenl•, <br />0 other (explain) -- <br />REQUEST: (explain) __li(1�_—.E_!IJr•^tf <br />I hereby declare that the above stniemenis are True. <br />�xLl�turc <br />FOR OFEI(.r USE ONLY: <br />IIASE rCr.s,' <br />tiulydivision, motor <br />($15U) _----_. <br />subdivision, miunr <br />($Ti) <br />rezoning <br />conditinoai u;e <br />variance <br />($50) <br />code appeal <br />($50) <br />subtutal <br />,loasr: fees In parcnlhosis are non- <br />refundable. <br />Park fond dedication -_ <br />date paid <br />receipt d <br />AO011IONAL FEES <br />poldir, luvartng untirrs __.._...._.— <br />::I:orr, con•,ultant reviews <br />miacrliruu•r.u•+ <br />vgrof rost.Mt.•r <br />sub tnIaI— <br />TOTAL ranP,O. <br />date paid <br />recelpl p <br />