Town of Kippens


Permit No: _______

Applicant: _________________ Phone: _________________ Date: _________________



Property Owner: ________________________________________________________________

Property Owner Address: _________________________________________________________


Contractor: _________________ Address: ________________ Phone: ________________

Type of Permit

Building (all structures): _____ Development Approval: _____ Approval in Principle: _____

Change/New Occupancy: _____ Repairs/Renovations: ______ Demolition: _____

Residential Subdivision: ______ # of Proposed Lots: ______ Fence: _____

Development Location: ______________________________ Construction Value: ___________

Description of Land To Be Developed

Frontage: _________ (m/ft) Depth: _________ (m/ft) Area: _________ (m2/ft2)

As per Survey: ________

Existing Land Uses (check appropriate box(es) & specify)

Residential: ____________ Crown Land: ___________ Unknown: ___________

Commercial: ____________ Vacant: ___________ Other: ___________

Describe Intended Use

If Residential:

Single Family Dwelling: ___ Single Family Dwelling w/Apartment: ___ Extension to Dwelling: ____

Add Apartment to Existing: ____ Accessory Bldg (shed/garage): ____ Other: _____

If Commercial:

Retail: _____ Industrial: _____ Extension to Building: _____ Office: _____

Restaurant: _____ Other: _____

Describe Building (if applicable)

Dimension: ____ x ____(m/ft) Area: _____(m/ft2) Height: _____(m/ft) Setback: _____(m/ft)

Heating Type: _________________________ # Washrooms: ______ Attached Garage: Y / N

Propane/Oil/Electric/Wood Appliances: ______________________________________

Describe Renovations, Repair, Extension, Etc. (Material Used):


Proposed Means of Access

Existing Access: _____ New Access (Culvert): _____ New Access (Subdivision): _____

I/We, _______________________________, the applicant(s) named herein, do solemnly declare the statements herein contained in this application are true and made with a full knowledge of the circumstances connected with the same, that the location and plot plan submitted correctly sets out the location of the development described in the said application. I/We make this solemn declaration, conscientiously believing it to be true and with full knowledge of the property owner, and knowing that it is of the same force and effect as if made under oath.

2 Juniper Avenue, Kippens, NL, Canada A2N 3H8

T: 709-643-5281 * F: 709-643-9773 * E: *

Town of Kippens


Please indicate the proposed location of the new building in relation to the Lot Lines.

Indicate the location of accessory buildings, fences, and extensions in relation to the existing building and the Lot Lines. Also indicate the distance between the accessory building and the existing building. Please indicate driveway location.





Street Name and Number: _________________________________________________

2 Juniper Avenue, Kippens, NL, Canada A2N 3H8

T: 709-643-5281 * F: 709-643-9773 * E: *