Town of Amherst, New Hampshire
Office of Community Development
Building ∙ Code Enforcement ∙ Planning ∙ Zoning ∙ Economic Development
1. Type of Application: (check all that apply) Case #
___Accessory Structures ___ACWPD
___Construction of streets, roads, and other access ways ___Creation of water body
___Non-conforming Uses and Structures ___Open Space Plan
Planned Residential Development (PRD)
2. Project Name: ______________________________________________________________
3. Project Address: _______________________________ Map: _________ Lot________
4. Zoning District and Subdistricts: (check all that apply)
___Aquifer Conservation & Wellhead Protection District (ACWPD) ___Commercial Zone (C)
___Flood Plain Conservation District (FPCD) ___General Office (GO)
___Historic District (HD) ___Industrial (I)
___Limited Commercial (LC) ___Northern Rural (NRZ)
___Northern Transitional (NTZ) ___Residential/Rural (RR)
___Wetland & Watershed Conservation District (WWCD)
5. Primary Contact: __________________________ Email: _________________________
Applicant Owner Attorney Surveyor/Engineer Phone:
6. Applicant:
Address: City: State: Zip:
Phone: Email:
7. Owner's Name(s):
Address: City: State: Zip:
Phone: Email:
8. Surveyor/Engineer or Attorney (Firm):
Address: City: State: Zip:
Phone: Email:
9. Purpose of Plan: (as stated on plan)
10. Site Area: Existing Building Area: Add'l Building Area:
No. Stories: Percent Open Space: No. Parking Spaces:
(Note: Building Area refers to gross building area)
For an application to be scheduled on the next available Planning Board agenda, the following items SHALL be
submitted to the Planning & Zoning Department by close of business on the officially posted submittal date:
1. Completed and signed Conditional Use Permit Application Form
The application will not be placed on the Planning Board agenda unless all required signatures
are on the application. The owner SHALL sign the application form.
2. Four (4) large prints, five (5) 11"x17" prints and one PDF digital copy of the plan set
Plan(s) shall include all applicable information as described on the attached checklist attached
to the application. PDF files may be emailed or submitted via CD, DVD or thumb drive at the
time of application.
3. Completed Checklist, Waivers, and Abutters
The applicable checklist shall be completed as part of the application, including waiver requests
with appropriate documentation, and two (2) sets of gummed, typed, mailing labels for all abutters
as defined by RSA 672:3, including licensed professional on plan, owners, and applicants.
4. Application Fee and Abutter Mailing Labels
Fees will be determined at the time you turn in the application. Fees are based on the type of
permit and number of certified mailings which must be sent. All checks are to be made payable to
the Town of Amherst.
Fee Calcs: Fee per type of application $ 200.00 + ($7 x ____ abutters = $ _______) = $_________ total due
I/We have read the Conditional Use Permit Regulations and the Zoning Ordinance (as applicable). The
undersigned understands that the Amherst Planning Board must have a completed application on file
with the Planning & Zoning Department in accordance with the Planning Board's annual schedule of
meeting and deadline dates. I/We also certify that the abutters are as shown in the Town's records within
five (5) days of the filing of this application.
________________________________ __________________
Applicant's Signature Date
er(s): I/We, as owner(s) of the property described hereon, certify that this application is correctly
completed with all required attachments and requirements in accordance with the Conditional
use Permit Regulations and the Zoning Ordinance for the Town of Amherst. I/We also
authorize members of the Amherst Planning Board and its agents to access the property
described on this application for on-site review of the proposed application.
________________________________ __________________
Name (please print) and Title Date
If A
Owner(s) authorization for Applicant or Agent to represent the application:
The applicant or agent, as stated hereon, has authorization from the property owner to submit
this Conditional Use Permit Application and represent the property owner on matters relative
to the Town's approval process.
________________________________ __________________
Owner's Signature Date
2 Main St ∙ PO Box 960 ∙ Amherst,
NH 03031 ∙ 603-673-6041 ∙ v.3.11.14
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