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2. Completed applications are reviewed and approved at Select Board Meetings the first and third Mondays of every month or on the Tuesday following a Monday holiday. Plan work dates accordingly.
4. Name of Applicant:
6. Address of Applicant:
8. Phone Number:*
9. Email Address:*
11. Check one *

    1. Street
    2. Sidewalk
12. Check one *

    1. Total Blocking
    2. Partial Blocking
13. Dates of blocking*
    Dates of blocking should fall after the Select Board meeting date on which it will be reviewed. Select Board meets the first and third Mondays of every month.
15. Address of requested area to be blocked
17. Purpose/details of blocking
19. Attach required Insurance Certificate*
20. Detailed Map or Diagram
    If your request requires a street map or diagram please attach here.
22. Signature
23. Date
Leave This Blank:


31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit Submit and Print

* indicates a required field