Type of Application:

_____ Zoning _____ Subdivision _____ Conditional Use

_____________________________________________________________________________________

Name _______________________________________________________________________________

Address _____________________________________________________________________________

City _____________________________ State ________________ Zip _____________________

Telephone Number _________________________ (Business) _______________________________

Address of Subject Property _____________________________________________________________

Legal Description of Subject Property _____________________________________________________

____________________________________________________________________________________

Size of Land Parcel ____________________________________________________________________

Present Zoning _________________________ Proposed Zoning _____________________________

Present Use of Subject Property __________________________________________________________

____________________________________________________________________________________

Proposed Use of Subject Property ________________________________________________________

____________________________________________________________________________________

School District and Address _____________________________________________________________

____________________________________________________________________________________

Fire District and Address _______________________________________________________________

____________________________________________________________________________________

Describe Zoning and Actual Use of Adjoining Properties:

North _____________________________________________________________________________

South _____________________________________________________________________________

East _______________________________________________________________________________

West ______________________________________________________________________________

The Chief, Permits and Inspection Division, or authorized representative of Douglas County are hereby authorized to enter upon the property during normal working hours for the purpose of becoming familiar with the proposal.

Signature of Owner ___________________________ Date __________________

Signature of Authorized Agent ___________________________________________________

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(For Office Use)

Date Received ____________

Fee Received ____________

Received By ____________ rev. 11/99
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