APPLICATION FOR PUBLIC HEARING APPEAL OF ADMINISTRATIVE DECISION *AMOUNT OF FEE $855.00 Total including surcharge $923.40 Additional Radius Fee $ _______ Imaging Fee $60.00 See fee information and amounts on next page. FOLIO # ________________________ BY ____________________ Date Receipt Stamp Appeal to be heard by CZAB # ___________ Sec. _____ Twp. _____ Rge. _______ RADIUS ASSIGNED IMPORTANT – The applicant and/or the applicant’s attorney must be present at the hearing. 1. Name of Applicant (PRINT) ___________________________________________________ 2. Mailing Address ________________________________________ Tel No. _____________ _________________________________________________________________________ 3. Contact Person ____________________________________________________________ 4. Mailing Address _______________________________________ Tel. No. _____________ _________________________________________________________________________ E-mail Address of Contact Person _____________________________________________ 5. Name of Property Owner ____________________________________________________ 6. Owner’s Address __________________________________________________________ ____________________________________________________ Tel. No. _____________ 7. LEGAL DESCRIPTION OF THE PROPERTY COVERED BY THE APPLICATION (If subdivided, lot, block, complete name of subdivision, plat book and page number.) (If metes and bounds description – complete description, including section, township and range.) ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ 8. Address or location __________________________________________________________ 9. Size of Property _______ ft. x ________ ft. Acres ___________ 10. Administrative Decision appealed: (State in brief and concise language.) __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ American LegalNet, Inc. www.FormsWorkflow.com APPEAL OF ADMINISTRATIVE DECISIONS Page 2 11. Section and paragraph of regulations if applicable: (Copy regulations in detail) __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 12. Alleged error in the order, requirement, decision or determination made by administrative official in interpretation or enforcement of regulation: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ 13. Reason why the decision should be reversed: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ AFFIDAVIT I, ______________________________, being first duly sworn, depose and say that I am the party aggrieved by the action of the administrative official made the subject matter of this application, and that all of the foregoing statements and answers herein contained and the information herewith submitted are in all respects true and correct and honest to the best of my knowledge and belief. _____________________________ SIGNATURE Sworn and Subscribed before me This _____ day of ______________ *NOTE: _____________________________ NOTARY PUBLIC AN 8% SURCHARGE WILL BE ADDED TO ALL FEES EXCEPT DERM AND CONCURRENCY AND WILL BE IN EFFECT FROM 10/1/03 THROUGH 9/30/08. ADDITIONAL RADIUS FEES WILL BE CHARGED AT TIME OF FILING, IF AVAILABLE, OR WILL BE ASSESSED AND BILLED TO YOU AT A LATER DATE, IF APPLICABLE. A WEB IMAGING FEE OF $60.00 IS DUE AT TIME OF FILING. Rev. 9/30/03; 9/28/06 American LegalNet, Inc. www.FormsWorkflow.com