APPLICATION IS HERBY MADE TO:

( ) Use ( ) Erect ( ) Repair, remodel or extend a structure ( ) Excavate, grade or fill
at the following location:

PROPERTY OWNER’S NAME: ____________________________________________________

ADDRESS OF PROPERTY: _______________________________________________________

PROPERTY I.D. NUMBER: ________________________________________________________

SUBDIVISION NAME: ____________________________________________________________

LOT # _____________ LOT SIZE: ____________________________ ZONING:______________

IF NOT SUBDIVIDED ATTACH A COPY OF THE LEGAL DESCRIPTION OR DEED

TYPE: ( ) Residence ( ) Commercial Business ( ) Industrial ( ) Other______________

DESCRIPTION OF THE PROPOSED IMPROVEMENTS (please include dimensions, height,
materials and type of construction): _________________________________________________________________________________

_________________________________________________________________________________

Approximate date the work will commence: _____________________________________

Approximate completion date: _________________________________________________

SITE PLAN: Please attach a site plan showing all existing and proposed improvements on the
subject property. Include all of the following information: a north arrow, property lines and
dimensions, location of road and lake (if applicable), foot print of all buildings labeled existing
and/or proposed, dimensions of all buildings and their distance from all property lines,
location of survey stakes (if found), location and dimensions of all utilities, easements and
driveway, property code number and address. The owner must sign the site plan and date it.

FLOOR PLAN: Please attach a copy of a floor plan showing the location and dimensions of all
rooms. Please note internal improvements such as fireplaces and spas. The owner must sign the
floor plan and date it.

The attached Site Plan and Floor Plan, by this reference, are hereby incorporated and are part of
this application for a Land Use Permit. By signing below, the property owner or owner’s agent,
hereby represents that all information contained in this application is correct to the best of his or
her knowledge.

______________________________________________________ DATE___________________
SIGNATURE OF PROPERTY OWNER OR AUTHORIZED AGENT

LAND USE PERMIT APPLICATION

PAGE 2

MAILING ADDRESS: ____________________________________________________________

______________________________________________________________________________

PHONE NUMBER: (______) _________________________ EMAIL_______________________

FAX NUMBER: ( _____ ) ___________________________

CONTRACTOR: _______________________________________________________________

ADDRESS: ___________________________________________________________________

PHONE: _____________________________ LICENSE #: _____________________________

TOWNSHIP APPROVAL

( ) GRANTED BY VARIANCE DATE OF VARIANCE:_____________________________

( ) GRANTED BY SPECIAL USE PERMIT DATE OF S. U. PERMIT: ____________________

( ) GRANTED SUBJECT TO THE FOLOWING CONDITIONS:

_____________________________________________________________________________

_____________________________________________________________________________

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