$45 Fee Paid______ Date__________App#___________Name_______________________________

CORNWALL PLANNING AND ZONING COMMISSION

APPLICATION FOR ZONING PERMIT

Please type or print dark ink

OWNER/APPLICANT INFORMATION

Owner of record Applicant- (include permission note from owner) Name__________________________________ Name______________________________________

Address_________________________________ Address_____________________________________

Zip Code____________Tel________________ ZipCode______________Tel____________________

Signature______________________________ Signature_____________________________________

PROPOSED ACTIVITY and/or PROPOSED USE (Check where applicable and include 911 Address # if this is a new residence) 911 Address Number_________________

____New Driveway

____New Residence (#bedrooms& total sq. ft) Change of Use

_______________________________________ From_______________________

____Alteration to ________________________ To_________________________

____Addition to & (size)___________________

____Deck/Porch& (size)___________________

____Garage/Shed_________________________

____Studio(size)__________________________ The following uses will also require a

Special Permit Application:

_____Accessory Apartment

___ New Business in General Business Zone _____Apartment Use in Business Bldg.

Requires separate detailed Site Plan _____Conversion of Dwelling to Apts.

____ Home Business (4 different kinds)

_____Bed & Bkfst / Room & Board

LOT LOCATION AND DESCRIPTION

Zone (Check one): R-1___ R-3___ R-5___GB___ If applicable: ___AP ___FH ___HR

Street or Road__________________________________________ Lot Acreage_________

Building Setback from Nearest Point on Lot Boundary _______________________________

LOT AND SUBDIVISION HISTORY

Is the lot smaller than required for the zone in which it is located? _____ Yes _____ No

If answer is “No”, skip next three questions. If “yes,” Was it under single and separate ownership as of Sept. 1, 1965? ____Yes ____No If yes, Does the owner of this lot have an interest in any adjoining lot? ____Yes ____No and Did the owner have such an interest as of Sept. 1, 1965? ____Yes ____No

Was the lot part of a larger parcel at any time since April 10, 1954? _____Yes _____No

If “yes”, was acquisition of title to the lot made in accordance with Zoning and Subdivision Regulations? ____ Yes ____ No

If this lot was created by an approved subdivision, the name of the subdivision is ___________________________________________ and the lot number is ____________

PLOT PLAN Draw an approximate scale plan showing the following:

1. All property boundaries including Measurements & Area ( sq.ft.) & Adjacent Landowners

2 Dimensions of Existing Bldgs and Dimensions of New Construction with Number of Stories &

Height and sq. footage

3. Distances of All Bldgs. from Each Other & from Property Lines and the Relation to Road

OFFICE USE ONLY

Hous River Com_________ Erosion/Sedimen Pln_____________ IWWA Appr_____________

ZBA Approval Date___________ Town/DOT Driveway Permit#______________

P&Z Special Permit Approval Date______ TAH Dept Approval_____________

ZEO not apprvd date __________ apprvd date ________ Received Clerk___________________

Compliance Report Issued _______________ Permit Issued____________________