2. FEE $150
4. Property Address*
6. Legal Description*
8. Area in Acres
10. Present Use*
12. Proposed Use*
14. Reason for Request*
16. Applicant Name*
17. Applicant Email Address*
18. Applicant Phone Number*
20. Applicant Address*
22. City*
23. State*
24. Zip*
26. Site Plan*
28. I hereby certify that all information contained herein is true and correct, and that all required submissions have been submitted.
30. Typed Signature:*
31. Date and Time*
    Date and Time

    Date and Time
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33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

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