72-2U1) ^)
B)
C)
D)
occUR:
E) MAILING ADDRESS:
F) TELEPHONE NO.,:
APPLICATION TO THE 'BOARD OF SUP£RVISORS
The, following ..i:n£ormati'°n is t° 'b~ ,ty, ped..or printe~
NAME OF A?PLICANT.:
MAILING ADDRESS:.,
.....
NA~ OF P~SENT OWNER OF PROPERTY ON ~IcH THIS ~Q~ST WiLL
2)
IF THE APPLICANt,IS NOT THE OWNER OF THE PROPERTY'IN QUESTION,
EXPLAIN.: (Copy of pending contPact o~ option, agreement shall
be a~a~hed, he~eto: ~nd ~ade a'part~-of thi~ application.)
3)
LOCATION OF PROPERTY IN QUESTION
('Following infoPmation to be obtained f~om the
Office of the Co~n/fl/sesso~) '
C) SEC. NO. (3) D) SUBDIVISION NO. E) BLOCK NO. , ....
A PLAT. OF THIS PROPERTY SHALL BE ATTACHED HERETO AND MADE A PART
OF THIS APPLICATION SHOWING THE FOLLOWING:
LOCATION BY REFERENCE TO NEAREST ROAD INTERSECTION
DIMENSIONS OF SITE
4)
EXPLAIN FULLY THE TYPE OF USE PERMIT REQUESTED:
~ '/z~o ~ %u, ~biu~_. 'To. ;~ ~ .U~'.~.-~ .~.~ .... ~....~.c--~p
o~?~e,~- . ,,
5) STATE THE REASON FOR THIS REQUEST:7~d ~U)'D~. ~)~6 ~).Ei~ _O~//L'~fd '-~~'-
6) STATE HOW THIS RE:QUEST WILL NOT BE MATERIALLY DETRIMENTAL TO
THE ADJACENT PROPERTY OWNERS OR THE SURROUNDING NEIGHBORHOOD::-
' ~. ~. ,. a. ~ ~ ',
7)
STATE ANY EXISTING USE PERMIT OR VARIANCE GRANTED PREVIOUSLY ON
THE PARCEL IN QUESTION:
B) EXISTING ZONINgs.:
(PAGE 2)
9)
GIVE NAMES OF ALL OWNERS ADJACENT, ACROSS THE ROAD OR HIGHWAY
AND FACING THE .PROPERTY AND ANY OWNERS ACROSS ANY RAILROAD RIGHT_
OF WAY FROM SUCH PROPERTY° IN THE EVENT THE PROPERTY AFFECTED
IS SITUATED AT OR WITHIN 100 FEET ON THE INTERSECTION OF ANY
TWO OR MORE ROADS OR HIGHWAYS, AT OR WITHIN ONE HUNDRED FEET
OF THE INTERSECTION OF ANY ROAD OR HIGHWAY WITH A RAILROAD RIGHT-
OF-WAY OR AT OR WITHIN ONE HUNDRED FEET OF THE INTERSECTION OF
THE RIGHTS-OF-WAY OF ANY TWO RAILROADS, GIVE NAMES OF PROPERTY
OWNERS AT ALL CORNERS OF ANY SUCH INTERSECTION.
A) PROPERTY OWNER'S NAME: ~/~
TAX MAP NO. '~9-/$- SEC. NO. :~_S2~ ,, S~DIVISION NO.:
BLOCK NO.: LOT OR PARCEL NO.:
B) PROPERTY 'O~ER~ S NA~:
TAX MAP NO.: ~-~- SEC. NO. :( ~.J SUBDIVISION NO.:
BLOCK NO.: LOT OR PARCEL NO.:
TAX MAP NO.~.~-'/f SEC. NO. :~3 SUBDIVISION NO.:
BLOCK NO.: LOT OR PARCEL NO.:
D)
PROPERTY OWNER'S NAME:
MAILING ADDRESS:
TAX MAP NO.:
BLOCK NO.:
SEC. NO.: SUBDIVISION NO.:
LOT OR PARCEL NO.:
(PAGE 3)
E) PROPERTY OWNER'S NAME:
MAILING ADDRESS:
TAX MAP NO-.:
SEC. NO.:
SUBDIVISION NO.:
BLOCK NO.:
LOT OR PARCEL NO'.:
F)
PROPERTY OWNER'S NAME:
MAILING ADDRESS::
TAX MAP NO.:
BLOCK NO.:
SEC. NO.: SUBDIVISION NO.:
LOT OR PARCEL NO.:
G)
PROPERTY OWNER'S NAME:
MAILING ADDRESS:
TAX MAP NO.:
BLOCK NO,:
SEC. NO.: SUBDIVISION NO.'
LOT OR PARCEL NO.:
H)
PROPERTY OWNER'S NAME:
MAILING ADDRESS:
TAX MAP NO.:
BLOCK NO.:
SEC~ NO.: SUBDIVISION NO.:
LoT OR PARCEL NO.:
I)
PROPERTY OWNER'S NAME:
MAILING ADDRESS:
TAX MAP NO.:
BLOCK NO.:
SEC. NO.: SUBDIVISION NO.:
LOT OR pARCEL NO.:
J)
PROPERTY OWNER'S NAME:
MAILING ADDRESS:
TAX MAP NO.:
BLOCK NO.:
SEC. NO.: SUBDIVISION NO.:
LOT OR PARCEL NO.:
(PAGE
10)
THE APPLICANT HEREWITH DEPOSITS THE SUM OF TWENTY DOLLARS
($20.00) ATTACHED TO THIS APPLICATION, TO PAY THE COST OF
ADVERTISING NOTICE OF THE HEARING OF SAID BOARD TO ACT ON
THIS REQUEST. CHECK OR MONEY ORDER MUST BE MADE PAYABLE
TO: TREASURER: COUNTY OF CHESTERFIELD.
I/WE HEREBY DEPOSE AND SAY THAT ALL OF THE ABOVE STATEMENTS
AND THE STATEMENTS CONTAINED IN ANY EXHIBITS TRANSMITTED ARE
TRUE.
SIGNATURE OF APPLICANT
(Same name as used in item l-A,
page 1. )
SUBSCRIBED A~O SWORN TO BEFORe, ME T~S A ~,~ff^Y Or ~_~~o~9 ?,7
COMMISSION ~,XPIRES .~,~ ¢~, ~9 La
~;OTARY
(PAGE 5)