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01/17/23
CONDITIONAL USE PERMIT
STREET RIGHT-OF-WAY DEDICATION AGREEMENT
LOCATIONtADDR S:
DATE: oq I2-
DOCI�.E FORi1IEiTINtiON.
I do hereby agree !disagree to dedicate to the
public any needs right of --way as required by the Master Street Plan for a public street abutting
propert w•ned by me adjacent to the property requested for a conditional use permit.
1, .Z. - "f a ec disagr Ito provide at my expense an
easement deed an or other documents as necessary conveyi�ht-of-way to the public.
APPLICANTiOWNER �`�r t DATE
(If the above signature represents an applicant, attachment of a letter is required authorizing this
person to act in behalf of the title-holder_)