APPLICATION FOR A PERMIT
Prepared by State Planning Office

This publication is presented for "Classroom Use Only."  Its intended use is to stimulate and aid in discussion and role playing within a classroom setting.

Date_____________

The undersigned applies for a permit for the following use, said permit to be issued on the basis of the information contained within this application. The applicant hereby certifies that all information and attachments to this application are true and correct.

1 . Applicant

Name

Address

Zip Code

Telephone

2. Owner

Name

Address

Zip Code

Telephone

3. Address or location of property (describe or indicate on a map)

4. Existing use of property

5. Property is zoned as

6. Is property part of a subdivision? Yes__No__

7. Proposed use(s)

a) Residence

b) Accessory building

c) Pier or dock (Temporary__Permanent__)

d) Clearing for approved construction

e) Private sewage disposal system

f) Filling or other earth-moving activity of less than 10 cubic yds__
more than 10 cubic yds__

g) Other (explain)

8. Type of sewage disposal (existing____________ proposed___________)

9. Percentage of lot to be occupied by structures_______________.

10. Lot width____lot depth_____lot area______

11. Structures-exterior dimensions (length and width)

a) Residence_______by________Number of stories________

b) Garage_________by________

c) Other__________by_________Number of stories________

12. Site Plan. Illustrate the following information about your lot and the proposed use of the lot on a scale drawing or by a site plan prepared by a surveyor, architect, or engineer (use of graph paper as in the diagram to the right is recommended): a) Lot dimensions. b) Names of abutting property owners, name and location of abutting rights of way, public and private, and abutting water body. c) Exact location of existing and proposed buildings and distance of each from nearest lot line. d) Location of sewage disposal system and water supply. e) Areas to be cleared, if applicable. f) Areas of cut, fill, grading, or other earth moving activity, if applicable.

13. Attachments

a) Attach a copy of Plumbing Permit

b) Attach a copy of official decisions (or note pending applications) of other Federal, State, or local agencies regarding the use of this property (Site Location Permit, Minimum Lot Size waiver, Subdivision approval, Great Ponds Permit, etc.)

c) On a separate sheet, attach any supplemental information, or explain any points you feel need clarification.

To the best of my knowledge, all information submitted on this application is true and correct. All proposed uses will be in conformance with the application and the

_______________________.
(zoning ordinance)

Signature____________________ Date_________

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(For official use only - maintain as a permanent record)

Date Received ___________Fee Paid_________

Date of Action on Application______________Approved___Denied___

If application denied, reason for denial

If approved, the following conditions and safeguards were prescribed:

Code Enforcement Officer (if applicable)________________________

Planning Board (if applicable)__________________