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APPLICATION FOR PLANNING DEPARTMENT PERMIT <br />❑ Additional Farm Dwelling <br />4 <br />J Cluster Plan Development <br />❑ De Minimus Yard Encroachment <br />El Agricultural Project District <br />❑ Change of Zone <br />❑ Planned Unit Development <br />❑ Project District <br />Administrative Permits (Select At <br />._ . mn ............. 1__,. <br />❑ Non -Significant Zone Change <br />❑ `Ohana Dwelling <br />❑ Plan Approval <br />qg Commission Permits (Select <br />❑ Shoreline Setback Variance <br />❑ SMA Assessment <br />❑ SMA Major Permit <br />❑ Special Permit <br />�...__..m........................................... .__ -.... ........ -_____ _._, e , m _.. _ ......_ _... . <br />�.._..._ <br />PLEASE PRINT CLEARLY OR USE FILLABLE FORM <br />.._LIC _...R LANDOWNER... ..., ....... .�... <br />„APPLICANT/PETITONE� (S) (IF OTHER THAN APPLICANT) <br />Name: Name: <br />Mailing Address: Mailing Address: <br />City: 7 State: Zip: City. State: <br />Day Ph.: ( ) Email: Day Ph ( ) Email. <br />Signature: Date: Signature: Date: <br />CONSULTANT/REPRESENTATIVE OTHER <br />Name: Name: <br />Mailing Address: Mailing Address: <br />'ity State: Lip: City: State. Zip: <br />Day Ph ( ) Email Day Ph ( ) Email: <br />- ........... _...... _ ......... ......... _._ _ _ ........ _ ........ ..... .... <br />Signature: Date: Signature: Date <br />_.. <br />... __.. _..........J ... .,m._... ... . .... <br />Please indicate to whom the Planning Department Original: Copies <br />should send original correspondences and copies.m <br />Please Note: Signing the application above indicates that to the best of your knowledge, all the information provided for this application is true <br />and complete. It is understood that the Planning Director or Planning Commission may nullify any decision made in reliance upon information <br />given on this application form should there be any willful misrepresentation or willful lack of full disclosure on the part of the ,signee. <br />PROJECT INFORMATION <br />..................... ....... Key(s): (( ..�.._.._._.......... _....... .............._� _ _ ..............�....-...._....._.................._...._................_......_................... <br />'Tax Ma Ke s : 3 Size of Property or Affected Area(s): <br />... _...... .... ......-....-......... -- <br />Address(es): �� City: State: Zip: <br />........ ..— __.. <br />Project Description: <br />State Land Use. Zoning: LUPAG: SMA: <br />.. <br />County of i3awai`i Planning Department <br />East Hawaii Office: t` West Hawaii Office: <br />101 Pauahi Street, Suite 3`�ycy�Q[,1U74-5044 Ane Keohokalole Hwy <br />Hilo, Hawaii 96720 C Kailua-Kona, Hawaii 96740 <br />Phone (808) 961-8288 Phone (808) 323-4770 <br />Fax (808) 961-8742 Fax (808) 327-3563 <br />www.coholanningdept.com Hmvai'i County is an Equal Opportunity Provider and Employer 0anningno.hawaiicounty.gov <br />❑ Subdivision <br />❑ Subdivision Code Variance <br />❑ Zoning Code Variance <br />