Permit #
Applicant/Owners Name
Your email
Date
Applicant/Owners Address
City/State/Zip Code
Phone
Proposed Construction: NewAdditionAccessoryRenovationRepairOther
Description of Work:
Building Height:
Zoning District:
Proposed Setbacks: F: LS: RS: R:
PROPERTY ACCESS: ACCESS EASEMENT ON PROPERTY: YesNo
Water Source: Community SystemPrivate Well
Sewer Source: Community SystemPrivate Septic
IS PROPERTY LOCATED IN FLOODPLAIN? YesNo
ANY PROTECTED WETLANDS ON PROPERTY? YesNo
Tax Identification No.:
Deed Book & Page #:
Map Book & Page #:
Subdivision:
Signature:
By Submitting this form you agree that the above information is correct and the electronic signature are the legal equivalent of your manual/handwritten signature. Form will be emailed to Town Inspector upon submittal.
