Applicant Name

Applicant Phone No

Applicant Email

Applicant Address

Date (mm-dd-yyyy)

Applicant Signature

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Construction will agree with permit, plan, township zoning ordinance, and comply with local, state and federal laws. Owner and/or applicant agree to halt construction if conflict arises. Contact Zoning Administrator for staking inspection prior to construction. Permit expires in 12 months if work is not started. The zoning administrator has the right to inspect the property and construction at his convenience.

Owner Name

Owner Phone #1

Owner Phone #2

Owner Email

Owner Address

Contractor Name

Contractor Phone #1

Contractor Phone #2

Contractor Email

Contractor Address

Property Tax ID# 05-07-

Project Address

Zoning District

Wetlands on Property?

Steep Slopes?

Within 500ft of lake or stream?

Any permits already taken out?

If yes, type & number or attach copy.

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Date (mm-dd-yyyy)

Lot Width

Lot Depth

Lot Area

Setbacks from property lines:

Front

Rear

Right

Left

Structure Width

Structure Length

Structure Height

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Other (Desc)

Construction

Foundation

USE (Select)

Existing Bedrooms

Planned Bedrooms

Existing Bathrooms

Planned Bedrooms