Lewis County Community Development
Signature: __________________________________________ Date: ____________________
Check one: Owner
Authorized Agent
GENERAL INFORMATION
Property Owner Information:
Name: _________________________________________________________________________________________
Mailing Address: _________________________________________________________________________________
Phone Number: __________________________ E-mail: ________________________________________________
Tax Parcel Number (s): __________________________________ Zoning: ___________ Acreage: ______________
Site Address: ___________________________________________________________________________________
_______ Quarter Section, Section _______, Township _______ North, Range _______ East/West (Circle One)
Applicant (if different from owner):
Name: __________________________________________________________________________________________
Mailing Address: __________________________________________________________________________________
Phone Number: __________________________ E-mail: _________________________________________________
Tax Parcel Number (s): __________________________________ Zoning: ___________ Acreage: _______________
Site Address: ____________________________________________________________________________________
_______ Quarter Section, Section _______, Township _______ North, Range _______ East/West (Circle One)
Surveyor or Other Contractor Information (Attach additional sheets if necessary):
Name: __________________________________________________________________________________________
Mailing Address: __________________________________________________________________________________
Phone Number: __________________________ E-mail: _________________________________________________
Acknowledgment
I understand that County regulations require owner permission for County personnel to enter private property to conduct
permit processing, review, and inspections. I also understand that my failure to grant permission to enter may result in
denial or withdrawal of a permit or approval. By my signature below, permission is granted for representatives of the
Community Development, Environmental Health, and Public Works Department to enter and remain on and about the property
for the sole purpose of processing such permits and performing required inspections or reviews.
Prior notification of the date of inspections will take place is: Required Not Required
(________) ___________________ (Must provide phone number where applicant/representative can be reached)
I/We certify that all plans, specifications and other submissions required in support of this application conform to the
requirements of all federal, state, and local codes and applicable laws and ordinances; and I certify that I am either the current
legal owner of this property or their authorized representative. With this document, I take full responsibility for the lawful action
that this document allows.
I certify that I have read and understand the limitations and conditions of Lewis County Code and agree to comply with all
conditions of approval. I understand that any permits issued by Lewis County, consistent with the attached site plan, are valid
ONLY if construction is in according to this plan and all other conditions of the permit are followed. By my signature below, I
affirm that all the information and documents provided with this application are true and accurate to the best of my knowledge.
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