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Application - Plan Review City of La Vergne Planning Department 5089 Murfreesboro Road La Vergne, TN 37086 Revised 11/10/06 Phone: 615-213-2624 Fax: 615-213-8692 CITY OF LA VERGNE PLAN REVIEW APPLICATION For Staff Use Only Project Name: ___________________ Date: ____________ Fee: _________________ Please submit Application Forms in person to the City of La Vergne Codes Building Front Desk/City Planner Project Name: _____________________________________________________________ Project Address: ____________________________________________________________ Land Use Existing: __________________________________________________________ Land Use Proposed: _________________________________________________________ Existing Zoning District _______________________________________________________ Tax Map(s) & Parcel Number(s):________________________________________________ Check one or more of the following: _____ Concept Plan for Major Subdivision _____ Site Plan _____ Preliminary Subdivision Plat for Minor Subdivision _____ Variance* _____ Preliminary Subdivision Plat for Major Subdivision _____ Rezoning* _____ Final Subdivision Plat for Minor Subdivision _____ Road or alley abandonment _____ Final Subdivision Plat for Major Subdivision _____ Special Exception* _____ Final Subdivision Plat for Condominium *These requests require an additional application form. ****NOTE: A letter explaining the proposal must accompany all requests.**** Environmental Constraints on Site? 1. Are there slopes of 12-20% or greater on site? Yes No 2. Is the development located in a local regulatory flood plain/zone? Yes No Engineer/Designer (if applicable) Print Name _____________________________________ Address _______________________________________________ Zip Code ______________ Daytime Phone ________________ Fax ________________ E-mail: ______________________ Attorney (if applicable) Print Name _____________________________________ Address _______________________________________________ Zip Code ______________ Daytime Phone ________________ Fax ________________ E-mail _______________________ City of La Vergne Planning Department 5089 Murfreesboro Road La Vergne, TN 37086 Revised 11/10/06 Phone: 615-213-2624 Fax: 615-213-8692 Contact Person Print Name _____________________________________ Address _________________________________________________ Zip Code _____________ Daytime Phone ________________ Fax ________________ E-mail _______________________ The undersigned has read the application associated with the above listed review request and is familiar with the information submitted herewith. It is agreed and understood that the undersigned will be held responsible for its accuracy. The undersigned warrants their authority to bind the owner and to subject the property to restrictions and conditions that may be attached to the proposed development. Applicant (if other than owner) Print Name __________________________Signature __________________________________ Address ________________________________________________ Zip Code ______________ Daytime Phone ____________________ Owner(s) Print Name __________________________ Signature __________________________________ Address _______________________________________________ Zip Code ______________ Daytime Phone ____________________ Print Name _________________________ Signature __________________________________ Address ________________________________________________ Zip Code ______________ Daytime Phone ____________________ City of La Vergne Planning Department 5089 Murfreesboro Road La Vergne, TN 37086 Revised 11/10/06 Phone: 615-213-2624 Fax: 615-213-8692 Certification Statement I hereby certify that _________________________________________ is the owner of the property located at _____________________________________________________ which is the subject of this application, and that I, ______________________________, in my capacity as ______________________________________, am authorized to sign this application on behalf of the owner. I understand that knowingly providing false information on this Application may result in any action taken heron being declared null and void. I further understand that pursuant to TCA 39-16-301 et seq., knowingly making a material false statement, or otherwise providing false information with the intent to mislead a public servant in the performance of his duty is punishable as a Class B misdemeanor. _________________________________________ ____________ Signature Date _________________________________________ Printed Name and Title Note: A Certification Statement must be submitted with an application form requiring the owner’s signature if the owner of the subject property is a corporation, limited liability company, partnership, association, trustee, etc., or if someone other than the owner signs the application. All Certification Statements must be notarized. _________________________________________ ____________ Notary Signature Date