INSTRUCTION: Appeals of Administrative Adjustments must be filed within 15 days of the advertisement and can only be filed by an aggrieved party (neighboring property owner), but not the property owner of the subject site. Appeals of Administrative Site Plan Reviews have no deadline. APPLICATION FOR PUBLIC HEARING APPEAL OF ADMINISTRATIVE ADJUSTMENT OR ADMINISTRATIVE SITE PLAN REVIEW AMOUNT OF FEE: $957.95 (Total includes appeal, imaging fee and surcharge) RECEIPT # _____________________ FOLIO # ________________________ BY ____________________ Date Receipt Stamp Appeal to be heard by CZAB # ___________ Sec. _____ Twp. _____ Rge. _______ RADIUS ASSIGNED _500’_+ surcharge (Additional Radius Fee to be determined at a later date). 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. ______________ ________________________________________________________________________________ 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.) _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkflow.com 8. Address or location ________________________________________________________________ 9. Size of Property _______ ft. x ________ ft. Acres ___________ 10. Administrative Decision appealed: (State in brief and concise language.) _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _____________________________________________________ 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 ______________ _____________________________ NOTARY PUBLIC Rev. 11/21/01; 2/25/09 American LegalNet, Inc. www.FormsWorkflow.com