The undersigned applies for a permit for the following use. Said permit to be issued on the basis of the information contained within this application. The applicant hereby certifies that all information and attachments to this application are true and correct.

1. Applicant Name __________________________ Telephone_____________ Map____ Lot_____
   
   Address____________________________ (If applicant is not the owner please include owner’s
   Name:
2. Address or location of property _____________________ Address
   Phone Number )
3. Lot size (in acres) _______    Existing use of property_____________________________________
4. Is property part of a subdivision? Yes   No     Within 250’ of any water (lake, pond, brook or stream) Yes   No
5. Proposed use(s) Check all that apply: Residence   Accessory Building  
   Clearing for approved construction   Private sewage disposal system   Filling or other earth-moving activity   Commercial   Other (explain)___________________________________________________________
6. Type of sewage disposal (existing_____________________    proposed__________________________)
7. Proposed structures – exterior dimensions (length by width) Residence ______by _______
   Garage ______by _______ Other (please specify) _________  ______by _______
8. Site Plan: Lack of measurements in your site plan will delay the issuance of your permit. Items to include are: distance to boundary lines (minimum 20’; distance from any road (minimum 50’ except Maine St distance is 75’); distance to any highwater mark (streams and brooks to be included in site plan); location of existing & proposed buildings; location of sewage disposal system & water supply; areas of cut fill or other earth-moving. Please use the back of this form if more room is necessary.
9. Attachments:
   1. Attach copy of Plumbing Permit
   2. Attach a copy of official decisions (or note pending applications) of other Federal, State or local agencies regarding the use of this property (Site Location Permit, Minimum Lot Size Waiver, Subdivision Approval, Great Ponds Permit, etc.)
   3. On a separate sheet, attach any supplemental information, or explain any points you feel need clarification.

To the best of my knowledge, all information submitted on this application is true and correct. All proposed uses will be in conformance with the application and the Building Ordinance or the Shoreland Zoning Ordinance.

Applicant signature _____________________________________   Date _______________

(For Official Use Only – maintain as a permanent record)

Date received ____________

Date of action on application_____________ Approved   Denied  

Safeguards and conditions: Reason for denial:

 

 

Code Enforcement Officer _____________________ Planning Board Chairman __________________________
Derek DeSanctis,
15 Cullen Road
Stoneham, Maine 04231 (207)928-2030