Application for Use and Occupancy Permit and Building Permit, County of _________, Office of _________[e.g., County Building Commissioner]

Application is made for a use, occupancy and building permit under the provisions of ordinance [resolution] _________[describe] zoning territory _________[describe]. The undersigned applicant represents that all answers to the questions propounded and maps and drawings attached are true; that the permit applied for, if granted, is granted on the representation made; and that any permit issued may be revoked without notice on any breach of representation or condition.

Premises [lot, tract] located at _________[describe].

Name of owner of premises [lot, tract] _________, _________[address and telephone].

To be occupied by owner _________; by tenant _________; telephone _________.

For sale _________. Present use _________. Vacant _________.

Use under permit to be _________.

Estimated cost of total improvements contemplated $_____[no buildings][no construction cost].

Date construction to be started [immediately].

If this building is not started in six months, this permit is void.

It is understood that any permit issued on this application will not grant any right or privilege to erect any structure or to use the premises described for any purpose that is prohibited by the zoning regulations.

All provisions of the ordinance and resolution governing the use of property and the height, area and bulk of buildings will be complied with whether specified or not except any variations ordered by the _________ County Board of Adjustment.

Permit refused _________ Reason _________.

Permit granted by Board of Adjustment

— Yes — No

Date _________.

Permit No. _________.

Permit cost _________.

_________, County Building Commissioner

[or the like]

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