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TOWN OF SHAFTSBURY
SUBDIVISION APPLICATION

ZONING DISTRICT                              

LANDOWNER                                                                                                                                        

ADDRESS & PHONE NUMBER                                                                                                            

APPLICANT (IF OTHER THAN ABOVE)                                                                                                         

ADDRESS & PHONE NUMBER                                                                                                            

DEED REFERENCE: BOOK                         PAGE                         PARCEL ID                                    

                                                                                                                  (from tax maps: map/block/lot)

 LOCATION OF SUBDIVISION:                                                                                                             

 (street name and distance to nearest intersection)

 NAMES OF ADJACENT OWNERS                                                                                                        

                                                                                                                                                                 

those to whom written notification is required will be determined by the Planning Commission at the sketch plan

classification meeting

AMOUNT OF LAND INVOLVED: (acres)                                                                                               

NUMBER OF LOTS & ACREAGE EACH                                                                                                

PREVIOUS PERMITS ISSUED. MUNICIPAL OR STATE. REGARDING THE LAND IN QUESTION (include permit’s, names & dates  issued                                                                                                      

WILL LOTS HAVE DIRECT ACCESS FROM TOWN OR STATE MAINTAINED ROAD?

YES ___ NO

IF NO, NATURE OF ACCESS:

NEW ROAD BUILT TO TOWN SPECIFICATIONS?       ____YES ____NO

REQUEST WAIVER OF ROAD REQUIREMENTS?        ____YES ____NO

WATER SUPPLY TO PROPERTY:                                  ____PRIVATE  _____PUBLIC

WASTEWATER DISPOSAL:                                           ____ EXISTING _____ NEW (PROPOSED)

WILL A DEFERRAL BE REQUESTED ON SEWAGE REQUIREMENTS? ____YES ____NO

NAME ADDRESS & PHONE NUMBER OF CONSULTANT                                                                

                                                                                                                                                              

                                                                                                                                                              

LANDOWNER SIGNATURE & DATE

                                                                                                                                                              

APPLICANT SIGNATURE & DATE

 

NOTE: IT IS THE RESPONSIBILITY OF THE APPLICANT TO OBTAIN APPROVAL FROM THE

ROAD FOREMAN AND THE BUILDING INSPECTOR. THE PLANNING COMMISSION CANNOT APPROVE THE SUBDIVISION WITHOUT BOTH THE ROAD FOREMAN AND BUILDING INSPECTOR REPORTS.

 

THIS PAGE FOR OFFICE USE ONLY

THIS APPLICATION WAS RECEIVED BY ME:

                                                                                                                                                                 

ZONING ADMINISTRATOR & DATE

SUBDIVISION #:                                   

 

NUMBER OF LOTS:                             

SUBDIVISION CLASSIFICATION:  ____MAJOR  ____MINOR

FEE RECEIVED                                                     

($25/lot minor, $35/lot major, plus legal notice fees and $25/lot additional for wastewater disposal system review by

Building Inspector)

ADMINISTRATIVE OFFICER DATE & INITIAL WHEN EACH STEP IS COMPLETE:

SKETCH PLAN MEETING                                         

PRELIMINARY APPROVAL                                    

ADDITIONAL MEETINGS                                         

FINAL APPROVAL                                                    

MYLAR APPROVED BY CHAIR                              

MYLAR & PERMIT RECORDED                              

ROAD FOREMAN'S REPORT                                                                                                          

                                                                                                                                                          

BUILDING INSPECTOR'S REPORT                                                                                                

                                                                                                                                                          

SIGNATURE AND DATE:                                                                                                                  

CONDITIONS OF FINAL APPROVAL                                                                                            

                                                                                                                                                            

                                                                                                                                                            

                                                                                                                                                            
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