Receipt Stamp

PROPOSED PROJECT NAME -__________________________________

STREET ADDRESS_____________________

(must include 911 address if assigned)

PARTIES INVOLVED - Those listed below will receive Planner Reviews and Notices of Action by the Board.

APPLICANT ADDRESS	_________________________ _________________________ _________________________ _________________________	PHONE FAX E-MAIL	__________________________ __________________________ __________________________ __________________________
OWNER ADDRESS	_________________________ _________________________ _________________________ _________________________	PHONE FAX E-MAIL	__________________________ __________________________ __________________________ __________________________
AGENT ADDRESS	_________________________ _________________________ _________________________ _________________________	PHONE FAX E-MAIL	__________________________ __________________________ __________________________ __________________________

PROPERTY INFORMATION

Map_____ Street_______ Lot_______	Zoning District(s)___________________
Map_____ Street_______ Lot_______

PROPOSAL DESCRIPTION - Use the space below to write a brief description of the development proposal and how it will effect the existing use of the property. Use back if necessary.

1. Lot size(s) __________________

2. Number of units or lots existing and proposed ________________

3. Square footage of units or building ____________________

___________________________________ _________________________________

Property Owner’s Signature Agent’s Signature

___________________________________ _________________________________

Date Date