CITY OF ABSECON PLANNING BOARD

500 MILL ROAD

ABSECON, NJ 08201

PHONE (609) 641-0063 FAX (609) 645-5098

APPLICATION FORM FOR WAIVER OF SITE PLAN REVIEW

ABSECON CITY, NEW JERSEY

To be completed by City staff only

Date Filed:_____________ Application No.____________

Application Fee____________

Escrow Deposit_____________

Scheduled for: Review for Completeness____________ Hearing_________________

To be completed by applicant

SUBJECT PROPERTY

Location:_____________________________________________________________________________

Tax Map Page______ Block______ Lot(s)_____

Page______ Block______ Lot(s)_____

Dimensions Frontage_____ Depth_____ Total Area_____

Zoning District_________________________________________________________________________

APPLICANT

Name________________________________________________________________________________

Address______________________________________________________________________________

Telephone Number___________________________________________________________________

Applicant is a Corporation_______ Partnership_________ Individual_________ LLC__________

TAX IDENTIFICATION NUMBER__________________________________________________________

DISCLOSURE STATEMENT

Pursuant to NJS 40:550-48.1, the names and addresses of all persons owning 10% of the stock in a corporate applicant or 10% interest in any partnership applicant must be disclosed. In accordance with NJS 40:550-48.2 that disclosure requirement applies to any corporation or partnership which owns more than 10% interest in the applicant followed up the chain of ownership until the names and addresses of the non-corporate stockholders and partners exceeding the 10% ownership criterion have been disclosed. (Attach pages as necessary to fully comply.)

Name__________________Address______________________________________Interest_________

AGENT REPRESENTING APPLICANT (If Applicable)

Name________________________________________________________________________________

Address______________________________________________________________________________

Telephone Number___________________________________________________________________

If Owner is other than the applicant, provide the following information on the Owner(s):

Owner’s Name_______________________________________________________________________

Address______________________________________________________________________________

Telephone Number___________________________________________________________________

Interest ______________________________________________________________________________

Description of:

Existing Use, Number of Employees and Average Number of Customers Per Day

Proposed Use, Number of Employees and Estimated Number of Customers per Day

BUILDING ALTERATIONS

Interior – Non-Professional plans of existing and proposed conditions, drawn to scale, are encouraged and acceptable for waiver applications. Professional plans may be required by the Construction Code Official for actual construction.

Exterior

NUMBER OF ACCESS DRIVES AND LOCATION

PARKING

Number of Spaces__________________________

Truck Loading__________________________ _________________________

TYPE OF PARKING LOT COVER

Asphalt_____ Gravel_____ Crushed Stone_____ Other________

TYPE AND WIDTH OF PEDESTRIAN WALKS

LIGHTING

Existing

LIGHTING (cont’)

Proposed

SIGNS (Dimensions and Location)

Existing

Proposed

LANDSCAPING & BUFFERS

EXISTING UTILITIES

City Water Yes_____ No_____

City Sewer Yes_____ No_____

DESCRIPTION OF OTHER CHANGES TO SITE NOT LISTED ABOVE, IF ANY

SUPPORTING DOCUMENTS

Floor Plan - Required

Survey - Required

Previous Site Plan Yes____ No_____

Other_______________________________________________________

I certify that the foregoing statements and the materials submitted are true. I further agree to submit a full Site Plan Application within one year of Absecon Planning Board waiver of Site Plan review, should the Planning Board deem such further review necessary. I further certify that I am the individual applicant or that I am an Officer of the Corporate applicant and that I am authorized to sign the application for the Corporation or that I am a general partner of the partnership applicant.

[If the applicant is a corporation this must be signed by an authorized corporate officer. If the applicant is a partnership, this must be signed by a general partner.]

Sworn to and subscribed before me this

_____ day of ________, 20____.

NOTARY PUBLIC SIGNATURE OF APPLICANT

I certify that I am the Owner of the property which is the subject of this application, that I have authorized the applicant to make this application and that I agree to be bound by the application, the representations made and the decision in the same manner as if I were the applicant.

[If the owner is a corporation this must be signed by an authorized corporate officer. If the owner is a partnership, this must be signed by a general partner.]

Sworn to and subscribed before me this

_____ day of __________, 20____.

NOTARY PUBLIC SIGNATURE OF OWNER

I understand that the sum of $___________ has been deposited in an escrow account. In accordance with the Ordinance of the City of Absecon. I further understand that the escrow account is established to cover the cost of professional services including engineering, planning, legal and other expenses associated with the review of submitted materials. Sums not utilized in the review process shall be returned. If additional sums are deemed necessary, I understand that I will be notified of the required additional amount and shall add that sum to the escrow account within fifteen (15) days.

DATE SIGNATURE OF APPLICANT

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