Town of Charlotte, Vermont

Rental Housing Registration home

Date ____/____/____

Address of property___________________________________________________________________

Name of property owner___________________________________________ Phone _______________

Property Identification: Parcel ID # ___________________________________

Map # ___________Block # ____________Lot # ______________

Present Use of Property _______________________________________________________________

ÿ Single-Family ÿ Duplex ÿ Single-Family w/Apartment ÿ Farm Labor Housing ÿ Camp

Department of Labor & Industry Certificate of Occupancy Attached: ÿ Yes ÿ No

Signature of Property Owner: ___________________________________________________________

Received by: _______________________________

Date: ______/_______/_______

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FOR OFFICE USE ONLY

Signatures of following departments, if applicable, that Town regulations or conditions have been met:

Road Commissioner: _________________________________________________Date____/____/____

Engineer’s completion report: __________________________________________Date ____/____/____

Number of bedrooms _____ or GPD ________ for which the septic system was designed and built.

Sewage Officer _____________________________________________________Date ____/____/____

Zoning Administrator/site visit: _________________________________________Date ____/____/____

Outstanding items, if any: _______________________________________________________________

____________________________________________________________________________________