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VARIANCE/WAIVER REQUEST FORM
Date Filed " / - Z
01 / 18/23
Plat Narne VQCt -�, 09? WOW � File No.
Owner: _ I. ^ • ^ G L. Cr Engineer: ." f ti %AX S.
Address: c9 Z Address: r bit! ' •*4• Z
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Phone Phone: S 6 ;V y}
riance(.) Rcquested:
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Justification:e. As
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Owner's Signature: a 1..k—s� rtt Date 16-1 I ` z `i
PLANNING COMMISSION ACTION; BOARD OF DIRECTORS ACTION:
Approval ( ) Date Approval ( ) Date
Denial () Date Denial () Date
Basis for Decision: Basis for Decision: