PERMIT APPLICATION

Applicant’s Name, Address & Phone No.______________________________________
_______________________________________________________________________
Owner’s Name and Address (if different from above) ____________________________
_______________________________________________________________________
The location of this work (Town Hwy #, distance to nearest intersection, which side, include parcel map)_______________________________________________________
_______________________________________________________________________
Description of the work to be performed (attach sketch, include measurements)________
_______________________________________________________________________
Has zoning or Act 250 application been filed? __________________________________
If yes, application number or other identification if different from above _____________
_______________________________________________________________________
Date work expected to begin ________________________________________________
Applicant ___________________________________________________Date ________
Co-Applicant ________________________________________________Date ________

PERMIT APPROVAL

This permit is issued with the following directions, restrictions and conditions, and covers only the work described hereinafter, and then only when the work described is performed as directed, and subject to the following conditions on the reverse side of this application.
________________________________________________________________________

Work to be completed by: ____________Expiration Date (2 yrs from issue)___________

Date _________________ ____________________________________
Road Commissioner, Town of Hyde Park

NOTICE: This permit covers only rights vested in the Town of Hyde Park over this highway and it does not release the petitioner from the requirements of any other statutes, ordinances, rules or regulations. This permit is effective upon compliance with such of these other requirements as are applicable.

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