HomeMy WebLinkAboutPermit Miscellaneous 1978-9-4
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Environmental Management
ACTIVITY INFORMATION SHEET
COMPLETE THIS SECTION.
INCOMPLETE FORMS WILL BE REJECTED!
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PROPERTY O\~ilER/CONTRlICT PURCllllSER
:.1....ILI:1G i\DDRESS
:~...\I LIflG ADDRESS
CrTY
STATE
ZIP CQDE
CITY
STATE
ZIP CQuE
BUSI:.1ESS TELEPIlO::E ::U:-~3ER
(2) ~1J\IL HiF'OR.:'L:\TION TO:
HOI.tE TELEPHONE :lUi.1BER
o ,WPLICANT /REPRESEIlTATIVE
BUS ItlESS TELEPHOHE HU:.:Sl::R
1lD:-1E TELEPllo:a:: :IU;.:BER
o PROPERTY O\'iNER/CONTRi\CT PURCHASER
Q) Tr\X HAP/PROPERTY DESCRIPTION NUl-tilER (from tax maps in Department of Assessment & Tax<\tion or horn tax st,1tcme:nt):
Tax H.J.p Number:
Tax Lo.t(s):
--
"[J6uCoCT,C~--
By parti ticn f!
o~
)
Tax map nuMber of adjoining
property.- in" Silme ownership: 0 None
// -- 'j J.II T~X Lotls):
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. BLOCK:
TiJX i'>lap tJu!:lhcr:
(j) SUBDIvrSIO~ (i: .:IF?licnblc) ://~ f
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I
@ "-EQUEST (briefly cescri information needed):
COMPLETE THIS SECTION R LAND USE,
CONSTRUCTION APPLICATION , OR PROPOSALS. SEE 'NOTE
---.
Q) TOTJ\L CONTIGUOUS PROPERTY. IN SAME ONNER;:'I1H':
BELOW.
-------
acres
/**FOR
-,
STAFF USE ONLY**
NmlBER: ~ 10 1
Cl-4
(() c:...^
.TIME_INITIATED: ~
?f
DATE:
..,
IX
"
..,
l:"
o PROPERTY ADDRESS:
o PRESENT USE OF PROPERTY:
CHECKED BY:
r.lodulZlr home
RV in use as residence
Stor.Jge__
ATTACHED EXHIBITS:
o Plot Plans (2)
OConstr. pl.1.ns (2)
@ nUi.lBER OF 5TRUCTt:RES ON PROPER'l'Y: Stundard home Hobilc home
G.Jraqe
Shop_
Barn
o Site PIun
o Copy of Tax t-lap
o Othcr
.
Other (~p(.:ci f;')
o I\CCESS 'i'{) P~O;'EP.'!"{: publ ic HOud llamc
SCREENING VERIFICflTION:
Private HOild Name
, of
By:
p.Oud E.l~;em~nt
Hidth
U-S\1rs
D~ltc :
(0 0711ER EI\S!~:.:E:!'1'S OVER PROPERTY:
'rime In:_Out:
o V:,\'I'EI: 111:;':'HICT:
8> FInE nISTI<ICT:
o Acccpt 0 "eject
Routed to:
<.) \':-: I ~;T ~ ::l; PEF':'117S 0:; 1'1,OPERTY:
"iiOTF.:
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(OVt:R)
ATT,\CIl A COPY 01-' T,\:>: :,tAP;
SHQ'",":j I:XIS:TlG STRCCTURl:S
...::D 'f,;X LOTS Itl YOUR o:\~~-
!-:F.SHIP. eBTAI:: TAX :-"J"r
I:l-SELF IlELP /",R1-;".