HomeMy WebLinkAboutAD-23-01 - Supplemental - 0500 Old Farm Road (2)
575 Dorset Street South Burlington, VT 05403 tel 802.846.4106 fax 802.846.4101 www.sburl.com
Permit Number AD-______-__________ (office use only)
APPLICATION FOR MINOR LOT LINE ADJUSTMENT
All information requested on this application must be completed in full. Failure to provide the requested
information either on this application form or on the plans will result in your application being rejected and a
delay in the review by the Administrative Officer.
1) OWNER(S) OF RECORD (Name as shown on deed, mailing address, phone and fax #)
2) LOCATION OF LAST RECORDED DEED(S) (Book and page #)
3) APPLICANT (Name, mailing address, phone and fax
4) APPLICANT’S LEGAL INTEREST IN THE PROPERTY (fee simple, option, etc.)
5) CONTACT PERSON (Name, mailing address, phone and fax #)
5a) CONTACT EMAIL ADDRESS
6) PROJECT STREET ADDRESS
7) TAX PARCEL ID # (can be obtained at Assessor’s Office)
8) PROJECT DESCRIPTION
a) Existing Uses on Property (including description and size of each separate use)
2 Minor Lot Line Adjustment Application Form. Rev. 12-2011
b) Other (list any other information pertinent to this application not specifically requested above, please note if
Overlay Districts are applicable)
9) LOT COVERAGES FOR EACH LOT
LOT #1 (Street Address):
a) Building: Existing % Proposed %
b) Overall (building, parking, outside storage, etc)
Existing % Proposed %
c) Front yard along each street Existing % Proposed %
(applies only to commercial property)
LOT #2 (Street Address):
d) Building: Existing % Proposed %
e) Overall (building, parking, outside storage, etc)
Existing % Proposed %
f) Front yard along each street Existing % Proposed %
(applies only to commercial property)
10) TYPE OF EXISTING OR PROPOSED ENCUMBRANCES ON PROPERTY (easements, covenants, leases, rights of
way, etc.)
11) PROPOSED EXTENSION, RELOCATION, OR MODIFICATION OF MUNICIPAL FACILITIES (sanitary sewer, water
supply, streets, storm drainage, etc.)
3 Minor Lot Line Adjustment Application Form. Rev. 12-2011
13) PLANS AND FEE
Plans shall be submitted which show the information required by the City’s Land Development Regulations. One
digital (PDF format) copy of all application materials as listed in Section 15.19(a) of the Land Development
Regulations, with plans provided as individual sheets and named to include sheet number and latest revision
date, must be submitted. An application fee shall be paid to the City at the time of submitting the application in
accordance with the City’s fee schedule.
I hereby certify that all the information requested as part of this application has been submitted and is accurate
to the best of my knowledge.
________________________________________
SIGNATURE OF APPLICANT
________________________________________
SIGNATURE OF PROPERTY OWNER #1
________________________________________
SIGNATURE OF PROPERTY OWNER #2
____________________________________________________________________________________
Do not write below this line
DATE OF SUBMISSION:__________________________________
I have reviewed this application and find it to be:
Complete Incomplete
________________________________________________________
Administrative Officer Date
The applicant or permittee retains the obligation to identify, apply for, and obtain relevant state permits for this
project. Call (802) 879-5676 to speak with the regional Permit Specialist.