PERMIT APPLICATION FOR ACCESS PERMIT
 
Residential, Agricultural, Commercial, Industrial, Development, Other

Owner's/Applicant's:       Name______________________________________________________

                                    Contact Name [if a business] ___________________________________

Address ____________________________________________________

Telephone Number ___________________________________________

Co-Applicant's:               Name______________________________________________________

 Address____________________________________________________

Telephone Number [If different from above] _______________________

Location of work [town, highway route and approximate distance (feet or miles) from the nearest intersection and which side ______________________________________________________________________________

___________________________________________________________________________________________

The undersigned request a Clarendon Access Permit to allow _________________________________________

to construct an access in accordance with Vermont Department of Highways Standards to serve the applicant's property, know as ________________________________________________, which is located on the _____________ side of _________________________________________________highway no. ____________

Date work expected to begin ___________________________________________________________________

The applicant agrees to maintain said access and adhere to the directions, restrictions and conditions forming a part of this permit.

Dated at ______________________________________. this _______ day of__________________, 20______.

PERMIT APPROVAL

NOTICE:  This permit is issued in accordance with Title 19, Chapter 11, Section 1111, V.S.A. relative to all highways within the control and jurisdiction of the Town of Clarendon, Vermont.  The issuance of this permit does not  release the applicant from any requirements of statutes, ordinances, rules and regulations administered by other governmental agencies.  The permit will be effective upon compliance with such of these requirements as are applicable and continue in effect for as long as the present land use continues.  Any change from the present land use will require a new permit.  This permit is issued subject to the directions, restrictions and conditions contained herein and any attachments hereto, and covers only the work described in this application, and then only when the work is performed as directed.

ISSUED DATE: ________________________

BY____________________________________     PRINT NAME: ______________________________________

   Authorized Representative for the Town of Clarendon, Vermont  5/00 LT