FORM 87-06 pg. 1
DIVISION OF BUILDING AND HOUSING
APPLICATION FOR PERMITTED USE CERTIFICATE
Fee: $ 200.00 Receipt #: _________________ Date: ________________
By: ___________
Filing Requirements:
1. One Copy of the Survey to Scale & Legible;
2. Three Copies of Floor Plans drawn to a scale of not less than 1/8" to 1 foot showing walls,
windows and doors, area separations and sanitary facilities;
3. One Copy of the Certificate of Occupancy for the Premises;
4. Copies of the First Page and the Signature Page of the Lease, if applicable; and
5. A Copy of the Decision by the Zoning Board of Appeals with Exhibits, if applicable.
Zone: ________________ Tax Map #: 0400 - ________ - _________ - _________
SECTION BLOCK LOT
Property Address: ________________________________________________________
________________________________________________________
Filed Map: ______________________________________________________________
Property Description: ______________________________________________________
[N/S/E/W SIDE OF ROAD – DISTANCE & DIRECTION TO INTERSECTION]
Name of Intended Business: ________________________________________________
Mailing Address: _________________________________________________________
[IF DIFFERENT THAN ABOVE]
Intended Use: ____________________________________________________________
_______________________________________________________________________
Occupancy Classification: * [See Page Two] ___________________________________
Last Use: _______________________________________________________________
[ATTACH A COPY OF THE PERMIT CARD OR CERTIFICATE FOR THE LAST USE]
Name of Applicant: _______________________________________________________
[PRINT OR TYPE]
Address of Applicant: _____________________________________________________
_____________________________________________________
Telephone of Applicant: ____________________________
Applicant’s Signature: ____________________________________ Date: ____________
Name of Property Owner: __________________________________________________
[PRINT OR TYPE]
Mailing Address of Property Owner: __________________________________________
__________________________________________
Property Owner’s Signature: ________________________________ Date: ___________