Form 76-005 - Petition For Waiver Or Variance (Page 2 of 2) in pdf

Petition for Waiver or Variance

page 2

Does the petitioner know of any cases of waivers that are either already decided or applied for (with the department)

that are similar to this request for waiver or variance.

________________________________________________________________________________________

Please provide the names, addresses and phone numbers for those persons or organizations that will be adversely

affected by the granting of this waiver or variance (including any public agency or political subdivision):

___________________________________

_________________________________________

___________________________________

_________________________________________

___________________________________

_________________________________________

___________________________________

_________________________________________

___________________________________

_________________________________________

___________________________________

_________________________________________

___________________________________

_________________________________________

___________________________________

_________________________________________

Please provide the names, addresses and phone numbers for those persons or organizations that have knowledge of

relevant facts of this waiver or variance:

___________________________________

_________________________________________

___________________________________

_________________________________________

___________________________________

_________________________________________

___________________________________

_________________________________________

___________________________________

_________________________________________

___________________________________

_________________________________________

___________________________________

_________________________________________

___________________________________

_________________________________________

Petitioners must obtain a signed release from persons or organizations with knowledge of relevant facts for this waiver

or variance.

If the petitioner wants identifying details deleted from the public file and the deletions are authorized by statute, each

detail must be listed with the statutory authority for the deletion.

Name of Petitioner: ____________________________________________

(Please Print)

By signing this document below, the petitioner is attesting to the truth and accuracy of the information set forth in this

document.

Signature of Petitioner: _________________________________________ Date: ________________________

76-005 09/01/01

Form 76-005 - Petition For Waiver Or Variance Page 2

Related Articles

Related forms

Related Categories