ATTACHMENT 11. - PLANNING BOARD APPLICATION COVER SHEET

(This sheet is to be completed by the applicant and attached to the respective checklist.)

Type of application (check one):

Administrative Subdivision: _____

Minor Subdivision: _____ Preliminary Plan _____ Final Plan _____

Major Land Development/Major Subdivision: _____

Informal Concept Plan Review _____

Master Plan _____ Preliminary Plan _____ Final Plan _____

Other: ___________

Name of Development/Subdivision: _____

Location of Development/Subdivision: _____

Owner: ___________

Address: ___________

City/Town/Zip: _________________________ Phone: _____

Applicant (if other than owner): _____

Address: _____

City/Town/zip: _________________________ Phone: _____

Notarized authorization to represent owner attached (Sec. 23-46 par. e, Land Dev./Subdiv. Regs.): _____

Preparers of Plans (e.g., surveyor, biologist, engineer, other (specify)):

Name: _________________________ Occup: _____

Address: _____

City/Town/zip: _________________________ Phone: _____

Signature/Certification:

The signatory certifies, by signature, that they are legally authorized to act on behalf of the Owner/Applicant. In addition, the Owner/Applicant, jointly and severally, by signature, duly acknowledges and agrees to reimburse the Town for all costs incurred for the adequate review and hearing of applications, issuance of permits and recordings of subsequent decisions, in accordance with RIGL 45-23-58. Failure to do so within a 30-day period after notification shall result in a lien being recorded against the property that is the subject of the application before the Planning Board. Signature _____

(Owner/Applicant) Date _____

Received by _____

(Planning Board) Date _____