Zoning Permit Application

Village of Ellsworth, Antrim County, Michigan
6520 Center Street, Ellsworth, Michigan 49729
Phone: 231.588.7411 / Website: www.villageofellsworthmi.com
Zoning Administrator: Jerry Rasmussen cell: 231-675-2828

PLEASE COMPLETE THIS FORM AND SUBMIT TO THE VILLAGE OF ELLSWORTH WITH THE FOLLOWING ITEMS (as applicable)

Health Department of Northwest Michigan (well/septic)
Soil Erosion Permit from Drain Commissioners office
Driveway Permit (Antrim County Road Commission or M-DOT)
Any required Michigan Department of Natural Resources permits

Zoning Permit Application Form

Property Information

Parcel #

Property Address *

Name of Property Owner(s) *

Property Owner’s Current Mailing Address

City

State

Zip

Phone

Description of Proposed Improvements:

Applicant’s Address:

Applicant's Name

Applicant's Phone

Applicant's Email

Dimensional Site Plan

A detailed sketch is required and must include all structures on the property, proposed structures with dimensions (including heights), parcel dimensions, setbacks from lot lines, and road rights of way. Dimensions shall include drip edges, not only foundations.

Affidavit

Affidavit: The undersigned affirms that he/she is the

owner

agent

lessee

or other interested party

involved in this petition and that the foregoing answers, statements and information are in all respects true and, to the best of his/her knowledge, correct. By making this application, the undersigned grants all officials, staff and consultants of the Village of Ellsworth access to the subject property as required and appropriate to assess site conditions in support of a determination as to the suitability of the proposed project and/or current or future Zoning Ordinance compliance.

By typing your name below, you agree that this constitutes a legally binding signature, equivalent to a handwritten signature.

Signature

Date

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