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Application - Stormwater Appeals and Advisory Board City of La Vergne, Tennessee 5093 Murfreesboro Road, La Vergne, TN 37086 ♦ (615) 793-6295 Application - Stormwater Appeals & Advisory Board APPLICANT INFORMATION (Please Print or Type - Any Correspondence will be addressed to the individual.) 1. Date of Application: ________________ 2. Contact Phone Number: ________________ 3. Property Owner’s Name: ______________________________________________________ 4. Property Owner’s Address: ______________________________________________________ ______________________________________________________ 5. Contact Name (If Different): ______________________________________________________ 6. Contact Address: ______________________________________________________ ______________________________________________________ 7. Property Location (If Different): ______________________________________________________ 8. Property Tax Map and Parcel: ______________________________________________________ Section 1 - Appeal a Decision made by the City Engineer or Codes Director. 9. Decision of the City Engineer or Codes Director: ________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ (If additional space is needed, please use an additional sheet of paper.) Section 2 - Apply for a Variance from the Waterway Buffer Policy. 10. Amount of Variance Requested (Must not exceed 35 feet): ________________________________ 11. Justification for the Variance Requested: ______________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ (If additional space is needed, please use an additional sheet of paper.) ___________________________________________ Date: ____________________ Applicant Signature