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01/2021 Owner Parcel # Mailing Address Permit # City Date Submitted State, Zip 60 Days Day Phone Fee Cell Phone Email Property Address Subdivision Twp Section______ Applicant Applicant Same as Owner Name Address 1 Address 2 City State, Zip Email Day Phone Clay County Planning & Zoning 3510 12th Avenue South, PO Box 280 Moorhead, MN 56561-0280 Tel (218) 299-5005 Application Fee: $225.00 Petition for Appeal of Administrative Decision ---PAGE BREAK--- 01/2021 We the undersigned do hereby respectfully petition the Clay County Board of Adjustment to appeal an administrative decision made by the Clay County Planning Director or the Clay County Planning Commission. Said appeal is being made in accordance with the provisions of 8-5-4C of the Clay County land Development Ordinance. 1. State the decision that is being appealed: 2. This decision was made by the: ❑ Clay County Planning Director ❑ Clay County Planning Commission 3. Describe the nature of and the justification for your appeal: 4. State the outcome that you desire from the appeal: To the best of my knowledge, I certify that the information provided on this application and accompanying documents is true and accurate. Applicant signature: ---PAGE BREAK--- 01/2021 Office Use Only Fee paid: Date paid: Hearing date: Final approval is: ❑ Granted ❑ Denied for the following reasons: Dated this of Chairperson, Clay County Board of Adjustment