19 16 VARIANCE/WAIVER REQUEST FORM

• Jurisdiction: Arkansas
• Library: Arkansas Form Book - Complete (2023 Ed.)

19-16 VARIANCE/WAIVER REQUEST FORM

Date Filed [date]

Plat Name: [plat name]
Owner: [owner name]
Address: [owner address]
Phone: [owner phone number]

File No.: __________
Engineer: [engineer name]
Address: [engineer address]
Phone: [engineer address]

Variances Requested:

1. [list variances requested in numbered paragraphs]

Justification: [describe justification for variances requested]

Owner's Signature:__________ Date:__________

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