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Variance Request 070924
subd.doc 5 01/18/23 VARIANCE/WAIVER REQUEST FORM Date Filed Plat Name n File No. Owner: r er o,-Ikio , Engineer: 14,cr�* � Address: 1-1 E `7 f 10-t" Address: S i? n D P-ue.�F-�� 17 r Phone: ;o1,C,2.0.1)10 :crew,.., •c-frrol1 01- Phone: .:; )' 114 . ® Mk• 1. c c: Variance(s) Requested: (1) _ (2) (3 ) Justification: Owner's Signature: PLANNING COMMISSION ACTION: Approval ( ) Date Denial () Date_ Basis for Decision: Date BOARD OF DIRECTORS ACTION: Approval ( ) Date. Denial () Date_ Basis for Decision: