Application No. _______________________________________     Date: _____________
Permit or Relief Requested:          Appeal ___________    Variance ___________
                    Conditional Use Permit ____________
APPLICANT ______________________________  OWNER _______________________________
ADDRESS ________________________________  ADDRESS _____________________________
________________________________________  _____________________________________ 
TELEPHONE ______________________________  TELEPHONE ___________________________
Legal relationship of applicant to property owner: ____________________________
Purpose of Permit:_____________________________________________________________
Property Location______________________________________________________________
                                Plat Book ____________ Page ___________________
                                Lot Size _____________ Zoning District ________
Number of Buildings Proposed: _________________________________________________
Gross Floor Area of Proposed Buildings: _______________________________________
Area of Land to be Disturbed: _________________________________________________
Estimated Cost of Project: ____________________________________________________

                                  _____________________________________________
                                  Signature of Applicant