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01/17/23
CONDITIONAL USE PERMIT
STREET RIGHT-OF-WAY DEDICATION AGREEMENT
LOCATION/ADDRESS: __5 ' a
DATE: / - a (,/ - a a"
DOCKETED FOR MEETING ON:
I, r do hereby agree / disagree to dedicate to the
public any needed/right-of-way as required by the Master Street Plan for a public street abutting
property owned by me adjacent to the property requested for a conditional use permit.
disagree to provide at my expense an
such right-of-way to the public.
APPLICANT/OWNER 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.)