DOCKET#_____________________

DATE FILED: __________________

NAME OF APPLICANT:______________________________________________________

ADDRESS OF APPLICANT: _________________________________________________

OWNER OF PROPERTY: _____________________________________________________

ADDRESS OF PROPERTY OWNER:__________________________________________

DESCRIPTION OF PROPERTY IN QUESTION: ATTACH DEED

PRESENT ZONING OF PROPERTY:___________________________________________

I hereby make application for a ---- VARIANCE/SPECIAL EXCEPTION(circle one) to

allow_________________________________________________________________________

Has appeal or application heretofore been filed with the Board for the premises?_____

If so give date:_________________

ADDITIONAL INFORMATION:_________________________________________________

MEETING DATE.,_______________________________

TIME: __________________________________________

PLACE: County Commissioners Room

FEE: $75.00

SIGNED:

__________________________________________

(applicant)

__________________________________________

(owner)

PHONE,__________________________________