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Town of Sennett Zoning Board of Appeals (ZBA) Common Application Form Address: Name : Applicant: Address: Name : Record Owner: If requesting an Area Variance, Use Variance or Special Use Permit, please also complete and attached the insert application form for the appropriate request. ZBA Common Application Form, Page 1 Appeal No.: Reason for Appeal: I, herby appeal to the Zoning Board of Appeals in regards to the application for building permit denied by the Code Enforecement Officer dated: (name of applicant) AND/OR The undersigned hereby makes application for (check one): Interpretation Special Use Permit Area Variance Use Variance pursuant to section of the Town of Sennett Zoning Local Law Property Location: Tax Map ID No.: Zoning District: Have any previous appeals been made with respect to the decision of the Code Enforcement Officer or with respect to the above referenced property? Yes* No *If Yes, please describe below the date of appeal(s), nature of appeals(s) and outcome of appeals(s): Address: Name : Owner: Applicant (if different than owner) Contact Information: Telephone: E-mail: Date: Previous Appeal: Address: Name : Telephone: E-mail: ---PAGE BREAK--- Address: Name : Professional Advisor(s) architect, engineer, surveyor, attorney, other): Type of Advisor: Firm: Office Phone: Other: E-mail: Name & Mailing Address: Adjacent Across Road Check One: Is subject property within 500 feet of: 1. Town of Sennett Boundary line? 2. State or county thruway/highway/roadway? 3. Existing or proposed state or county park/recreational area? 4. Existing or proposed county-owned stream or drainage channel? 5. Existing or proposed state of county-owned parcel on which a public building or institution is situated? 6. A farm operation located in an agricultural district? No Yes No Yes No Yes No Yes No Yes No Yes ZBA Common Application Form, Page 2 Name & Mailing Address: Name & Mailing Address: Name & Mailing Address: Adjacent Across Road Check One: Adjacent Across Road Check One: Adjacent Across Road Check One: Address: Name : Type of Advisor: Firm: Office Phone: Other: E-mail: Professional Advisor(s) architect, engineer, surveyor, attorney, other): Professional Advisor(s) architect, engineer, surveyor, attorney, other): Notification to Surrounding Property Owners: Please provide the name of the owner and mailing address for all adjacent properties to the property subject to the appeal, as well as properties located directly across a public or private road. ---PAGE BREAK--- Agricultural Data Statement 1. Is the property within an Agricultural District containing a farm operation(s)? 2. Is the the property within 500 feet of a farm operation located in an Agricultural District? No Yes* No Yes* *If Yes to either question, provide the name, address and Tax Map ID# of land owners containing farm operations located within an Agricultural District and within 500 feet of the application property. This is NOT required for Area Variances. Name & Mailing Address: : Name & Mailing Address: : Tax Map ID# Tax Map ID# General Municipal Law Section 809 Certification: In accordance with Section 809 of the General Municipal Law of the State of New York, the undersigned certifies in submitting this application that no officer or employee of the Town of Sennett is interested in granting said application: It is understood that: A person is "interested" in such application when he/she or his/her spouse of his/her brothers, sisters, parents, children, grandchildren or spouse of any of them: a. Is the applicant, or b. Is an officer, director, partner or employee of the applicant; or c. Legally or beneficially owns or controls stock of a corporate applicant or is a member of a partnership or association applicant; or d. Is a party of an agreement with such an applicant, express or implied, whereby he/she may receive any payment or other benefit, whether or not for services rendered dependent or contingent upon the favorable approval of such application, petition or request. Any person who knowingly and intentionally violates the provisions of Section 809 of the General Municipal Law should be guilty of a misdemeanor. The applicant hereby states, pursuant to the provisions of Section 809 of the General Municipal Law, the name, residence, and the nature and extent of the interest of any Town of Sennett officer with this application: Name & Residence Address: Applicant Owner ZBA Common Application Form, Page 3 Nature of Relationship: