72-5Ul) A)
*l~or office us< snly ~
*CASE NO. ~ / ~f'' ~ 'r
*REVIEW BY P.C. *
APPLICATION TO THE BOARD OF SUPERVISORS
Th~ fol!0wing_infp.Mmation is to be, typed .pr printed
NAME OF APPLIC~1T: ~-u/~/
B) MAILING ADDRESS:
c) TE PHO NO.: Z -- .....
D) NAME OF PRESENT OWNER OF PROPERTY ON WHICH THIS REQUEST WILL
OCCUR:
F) TELEPHONE
IF THE APPLICANT IS NOT THE OWNER OF THE PROPERTY IN QUESTION,
EXPLAIN: (Copy of pending contract or option agreement shall
be attached hereto and made a part of this application.)
3)
A)
c)
F)
LOCATION OF PROPERTY IN QUESTION
(Following information to be obtained from the
Office of the County Assessor)
MAGISTERIAL DISTRICT TAX MAP NO. ~/~
SEC. NO. D)
LOT OR PARCEL NO.
SUBDIVISION NO.
G) STREET ADDRESS
E) BLOCK NO.
A PLAT OF THIS PROPERTY SHALL BE ~TTACHED HERETO AND MADE A PART
OF THIS.APPLICATION SHOWING THE FOLLO~FING:
LOCATION BY REFERENCE TO NEAREST ROAD INTERSECTION
DIMENSIONS OF SITE
(PAGE 1)
~)
EXPLAIN FULLY THE TYPE OF USE PE]~MIT REQUESTED:
5)
STATE THE REASON FOR THIS REQUEST:
6)
STATE HOW THIS REQUEST WILL NOT BE MATERIALLY DETRIMENTAL TO
TRE ADJACENT PROPERTY OWNERS OR THE SURROUNDING NEIGHBORHOOD:
?)
8)
STATE ANY EXISTING USE PERMIT OR VARIANCE GRANTED PREVIOUSLY ON
THE PARCEL IN QUESTION:
A)
B)
EXISTING LAND USE:
(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: i
TAX MAP NO.: /~/~C. NO.: SUBDIVISION NO.:
BLOCK NO : LOT OR PARCEL NO :
B) PROPERTY OWNER' S NAME:
MAILING ADDRESS:
TAX MAP NO.:/?
BLOCK NO. '~
¢) PROPERTY OWNER'S NAME:
D)
,.' NO. .' SUBDIVISION NO.:
LOT OR PARCEL NO.: /~/
MAILING ADDRESS: '
.
TAX MAP NO. . C. NO.: SUBDIVISION NO.:
BLOCK NO.: LOT OR PARCEL NO.: /f%/'~
PROPERTY OWNER"S NA~: ~?'~,, f %. ~., ..... ,, ~.~- ~ .~
TAX MAP _NO. :/~/~-/ ~. NO, ~ SUBDIVISION' NO.:
B~C~ NO.: L~ OR PARCEL NO.: /'~'"~--
(PA~E 3)
E)
PROPERTY OWNER' S NAME:
MAILING ADDRESS: '~/~-
TAX MAP NO . NO :
BLOCK NO.:
SUBDIVISION NO.:
LOT OR PARCEL NO.:
F)
PROPERTY OWNER'S
MAILING ADDRESS:
TAX MAP NO.:
BLOCK NO.:
NAME:
SEC. NO.: NO.:
LOT OR PARCEL NO.:
PROPERTY OWNER' SNAME.'
MAILING ADDRESS:
TAX MAP NO.:/7~(~SEC. NO.:
BLOCK NO.:
SUBDIVISION NO.:
LOT OR PARCEL NO.:
H)
PROPERTY OWNER'S
MAILING ADDRESS
TAX MAP NO.:
BLOCK NO.:
NO.: SUBDIVISION NO.:
LOT OR PARCEL
I) PROPERTY OWNER'S NAME:
MAILING ADDRESS:
TAX MAP NO.:
BLOCK' NO.:
C. SUBDIVISION NO.:
LOT OR PARCEL NO.: ~
PROPERTY OWNER'S NAME:
MAILING ADDRESS:
TAX MAP NO. NO.:
SUBDIVISION NO.:
BLOCK NO.' LOT OR PARCEL NO.:
/
THE APPLICANT HEREWITH DEPOSITS THE .SUM OF~LARS
~ 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 DEPOgE AND SAY THAT ALL OF THE ABOVE STATEMENTS
AND THE STATEMENTS CONTAINED IN ANY EXHIBITS TRANSMITTED ARE
TRUE.
SIGNATUSE 8F A~LIC~T--'-~'
(Same name as used in item i-A,
page 1. )
S~SCRIBED AND SWORN To BEFORE NE THIS/,q~DAY o~
(PAGE 5)