DEVELOPMENT CLEARANCE PERMIT CERTIFICATE

TOWN OF WHITSETT

Sketch Lot and Structure with all Setback Requirements.

Street Number: Street Name:

Property_Address:_________________________________________________________

______________________________________Zip: ____________

Owner’sAddress: ___________________________ Phone Number:

___________________________ ________________________

___________________________ Zip: _____________________

Subdivision Name: ________________________________________________________

Section Number: _________________________ Block: ___________ Lot: __________

Tax Map ACL Number: ___________________ Block: __________ Parcel: ________

Purpose of Permit Certificate: _______________________________________________

Appropriate

Zone ___________________ Yes_____ No_____

Construction Type __________________ Yes_____ No_____

Use ______________________________ Yes_____ No_____

Water: Public_______ Private ________ Yes_____ No_____

Sewage Disposal: Public _____ Private _____ Yes_____ No_____

Parking: # of Spaces ______ N/A _________ Yes _____ No_____

Grading Permit Required: Yes_____ No _____ Permit Number __________

Restrictions/Limitations/Remarks:

*** PERMITS ISSUED FOR PERK TEST ONLY WILL REQUIRE A DEVELOPMENT CLEARANCE PERMIT CERTIFICATE FROM THE TOWN OF WHITSETT FOR ALL ADDITIONAL WORK OR IMPROVEMENTS.

_______________________________________________________________________

The undersigned parties hereby certify that the information given is correct and that a permit may be issued for the purpose stated so long as all other requirements are met. The permit is good for a period of twelve (12) months from date issued.

___________________________________ _____________________________________

WHITSETT TOWN OFFICIAL PROPERTY OWNER

DATE: ______________________ WHITSETT CONTROL NUMBER:_____________