P. O. Box 1746 Covington LA. 70434
Project___________________________________________________________________________________
Date Submitted_____________________________________
Name______________________________________________________________________________
Address___________________________________________________ Lot('s)#_____________________
Home Phone______________________________ Cell_________________________________________
Email Address_____________________________________
Plans Submitted Yes No
Explanation of Project (can use back if no plans submitted)
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Accepted... Date___________________________ Rejected...Date___________________________
Reason if rejected:______________________________________________________________________
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Signature of Board Member_____________________________________________________________