CERTIFICATE OF OCCUPANCY OR STATEMENT OF FACTS APPLICATION

TOWN OF SHAFTSBURY, VERMONT

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ZONING PERMIT NO._____________________ APPLICATION DATE:________________________

NAME OF CURRENT LANDOWNER(S):_________________________________________________

LANDOWNER’S ADDRESS:____________________________________________________________

PROPERTY LOCATION:_______________________________________________________________

PARCEL IDENTIFICATION NO.:______________ ERECTED:___________ ACREAGE:__________

PROPERTY DESCRIBED AS:___________________________________________________________

NAME OF APPLICANT:________________________________________________________________

ADDRESS:___________________________________________________________________________

SIGNATURE OF APPLICANT:__________________________________________________________

CERTIFICATE OF OCCUPANCY GRANTED________ DENIED________ DATE________________

STATEMENT OF FACTS GRANTED________ DENIED________ DATE_______________________

APPLICABLE PREVIOUS PERMITS:_____________________________________________________

COMMENTS:_________________________________________________________________________

This permit certifies that the building or use at the above location conforms to the approved plans.  Further, based upon the undersigned’s present knowledge, the undersigned is not aware of any violation of the zoning/building codes at the above-referenced property.  The undersigned has not completed a physical observance of the property.

_________________________________________________          ____________________________

Town of Shaftsbury, Vermont

Received for record this _________ day of ____________________AD 1999 at _______________.M.

and recorded in Shaftsbury Land Records Volume ___________ Page __________________.

Attest:_______________________________________________________, Town Clerk – Shaftsbury VT

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