Today’s Date

Applicant Name

Business Name

Location (address)

Description of Business

Business Owner

Contact Information (Phone No./ Email)

Property Owner

Contact Information (Phone No./ Email)

Dates Requested (Start Date/ End Date)

By signing below both the applicant and/or property owner acknowledge the following: the temporary
use permit, if granted, shall be granted for a specific time period, at the end of which, if the use
permitted has not been discontinued, it shall be deemed a violation of these land development
regulations and shall be punished as set out in article VII of this City’s Land Development Regulations.
Appropriate conditions and safeguards may include, but are not limited to, reasonable time limits
within which the action for which temporary use permit is requested shall be begun or completed, or
both. Violation of such conditions and safeguards, when made a part of the terms under which the
temporary use permit is granted, shall be deemed a violation of these land development regulations
and punishable as provided in these land development regulations.

Signature of Applicant

Signature of Property Owner