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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
25. Public Safety

    1. Approved
    2. Disapproved
26. Requirements of Approval:
    Note any requirements applicant must fulfill for approval of application.
28. Public Works

    1. Approved
    2. Disapproved
29. Requirements of Approval:
    Note any requirements applicant must fulfill for approval of application.
31. Code Enforcement

    1. Approved
    2. Disapproved
32. Requirements of Approval:

    Note any requirements applicant must fulfill for approval of application.

34. To be completed by the Select Board's office

    This application for the total or partial blocking of a street or sidewalk is hereby:

    1. Approved
    2. Disapproved
    3. Other/Rescind
36. Date Approved by Select Board
    Date Approved by Select Board

    Date Approved by Select Board
38. Signature
Leave This Blank:


40. 1. Receive an email copy of this form.
41. Email address

    This field is not part of the form submission.

42. Submit Submit and Print

* indicates a required field