45 WASHBURN ROAD

ALEXANDRIA, NH 03222

BUILDING PERMIT APPLICATION

Date Received:__________ Fee Paid: Cash_____ Check_______ Ck.#:______ Receipt #:______

Property Owner's Name:_____________________________________________

Property Owner's Address:___________________________________________

Applicant Name, if different:_________________________________________

NOTE: If the applicant is not the owner, a letter from the property owner giving the applicant authority

to act on his/her behalf must accompany this building permit applciation

Telephone: Home:____________ Work:____________ Cell:____________

Location of Property:

Road:_____________________________________ Map:____________ Lot:_______________

Building to be constructed: Residential:_______ Commercial:_______ Other:_______

If Other, please explain:_____________________________________________________

Dimensions: Length________ Width________ Height_______

Number of Bedrooms:__________________________________ Builder:__________________________________

Setback from roadway: ________Feet

FEES:

Residential One Unit:_______$100 / Residential Two Unit:______$100 / Residential Three Unit:_____$200

Residential Four Unit:______$250 / Commercial: _____$300

Prerequisites:

Is this property located in a Floodplain Area? _____Yes _____No

Septic System Design Approval Number:_______________ Date of Approval:______________

PUC Energy Compliance Approval Number: ____________ Date of Approval:______________

Driveway Permit Number or Date of Approval:______________________

Class VI Road Agreement: Date Signed:_________________________

(This agreement is necessasry only if you are constructing on a Class VI, Private Road or ROW)

Letter of Authority for Applicant to Act as Agent: Not Applicable _______ Attached_______

Property Owner/Agent Signature:_______________________________ Date:_________________

Selectmen's Approval to Construct: Date Granted:__________________________________

Selectmen's Signature:______________________________________

A furnace installation must be inspected by Fire Chief Francis Butler, who may be reached at 744-8987.

NOTE: The Town of Alexandria does not issue Certificates of Occupancy.

Revised 4/30/07