Application For Access Permit Form - Town Of Derby printable pdf download

APPLICATION FOR ACCESS PERMIT

TOWN OF DERBY

124 Main St, Derby, VT 05829

Fee: $33

rec. by on: ___________

date of application: ___________

Applicant: _______________________________________________________________

Mailing Address: _________________________________________________________

Daytime phone: _____________________ Evening Phone: ______________________

Property Tax ID #: ________________ 911 Address: ____________________________

The undersigned requests an Access Permit to construct an access or to make changes

(including but not limited to signs and fences) in accordance with Vermont Department of

Transportation Highway Standards to serve the applicant’s property.

Property located on the _______ side of Town Highway number TR- ________________

Road Name __________________________________, proposed access or changes will

be located approximately __________ feet from the intersection of this road with Town

Highway number TR- ____________, Road Name______________________________.

The proposed access dimensions and location are shown on the attached sketch plan, with

appropriate distances and dimensions noted. The applicant agrees to maintain said access

and associated improvements and adhere to the conditions imposed by this permit.

Applicant signature:_______________________________________

Property owner signature: __________________________________

ACCESS PERMIT

NOTICE: This permit is issued in accordance with Title 19, Section 1111, VSA relative to all highways within the control and jurisdiction

of the Town of Derby. The issuance of this permit does not release the applicant from any requirements imposed by other government

agencies. Permit is effective for as long as the current land use continues, any change in the current land use requires a new permit. This

permit is issued subject to the directions, restrictions and conditions contained herein and only the work described in the application and

permit is performed as directed. Violations are subject to the penalties set forth in Title 19, Section 1111, VSA of fines not less than $100

for each violation nor more than $10,000 for each violation.

CONDITIONS:___________________________________________________________

________________________________________________________________________

DATE: ________________ ROAD COMMISSIONER: _________________________

Application For Access Permit Form - Town Of Derby