Middlebury Planning and Zoning Commission
Application for Approval of Sub Division.

Is the subdivision in a watershed of a public water supply? Yes __ No __
If Yes, describe measures planned to avoid pollution and siltation. (attach a separate sheet if necessary) ___________________________________________

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Measures planned to prevent soil erosion during construction:

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Fee enclosed: $______ ($300.00 per lot)

The undersigned applicant(s) and owner(s) do hereby certify that the foregoing application and the documents listed above (whichare included as a part hereof) are true, correct and complete and hereby agree to complete the subdivision in accordance therewith (or as modified at the Commission's request) and the Zoning and Subdivision regulations of the Town of Middlebury, and if approved, to comply with all conditions (if any) imposed by the Middlebury Planning and Zoning Commission.

Dated at _______________, CT this ________ day of ________, 20__.

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Owner (or Agent hereuto duly authorized)

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Developer (or Agent hereunto duly authorized)* * Agent may sign only of a proper power-of-attorney or other satisfactory evidence of authorization is submitted with this Application.