![](https://var.fill.io/uploads/pdfs/html/28c861e5-a62d-4a03-b93a-378bc8fb3cec/bg1.png)
____ Applicants Initials P a g e | 1 October 2019
Revocations
City of Baton Rouge / Parish of East Baton Rouge
Office of the Planning Commission, 1100 Laurel Street, Suite 104
Baton Rouge, Louisiana 70802
Staff Use Only
Fee(s): ____________________________ Application Taken by: ________________
Receipt Number:____________________ Meeting Date: ______________________
MPN Project Number: _______________ Case Number: ______________________
Please Print or Type (all entities listed below will be copied on all comments)
1. Applicant Name and Title: __________________________________________________________
Email Address: __________________________ Daytime Phone Number: ____________________
Business: _______________________________________________________________________
Address: ____________________________ City: ____________ State: _________ ZIP: _________
2. Developer (if applicable): ___________________________________________________________
Email Address: ___________________________________________________________________
3. Name of Property Owner: __________________________________________________________
Email Address: __________________________ Daytime Phone Number: ____________________
Address: _________________________ City: _______________ State: _________ ZIP: _________
4. Subject Property Information:
CPPC Lot ID#(s): __________________________________________________________________
Lot #(s): _____________________________________________ Block/Square: _______________
Subdivision or Tract Name: _________________________________________________________
(If property is not subdivided, attach a complete legal description and a survey map indicating
bearings and dimensions.)
Nearest Intersection: ______________________________________________________________
5. Specific proposed use (Type of development and general background): ______________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
6. Actions requested: _______________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
7. Justification for action requested: ___________________________________________________
_______________________________________________________________________________
Date Received: _____________