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Appeal Fee:    $120.00
Noticing Fee:     55.00
Total Due       $175.00

Name: _____________________________ Daytime Phone: _____________

Appellant’s Address: ___________________________________________________________________

Address of Subject Property (if applicable): __________________________________

Date of Action: _________________________

Action being appealed: ___________________________________________________________________

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Reason(s) why you are appealing the action:

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_______________________________ Date: __________________
Signature of Appellant

An appeal must be filed with the Town Clerk within ten days of the Planning Commission action or receipt of written notice of the administrative action being appealed.