HomeMy WebLinkAboutMunicipal Facilities Exclusion timRevised 06/17
MUNICIPAL FACILITIES EXCLUSION CHECKLIST
Required under § 76-4-127 MCA
(formerly called master plan exclusion)
1. Does this subdivision affect property with an existing Title 76-4 Approval? Yes ____ No _____
If yes, then you may not use the Municipal Facilities Exclusion for this subdivision 2. Name of Subdivision:____________________________________________________________
3. Name and address of the applicant:__________________________________________________
__________________________________________________
4.Name and address of engineer: ____________________________________________________
____________________________________________________ 5. Location of the subdivision to the city or town, vicinity map attached: Yes ____ No _____
6. Copy of the Plat or Certificate of Survey or Unit Declaration and floor plan with exemptioncitation: Attached ____.
7. Number of parcels or units in the subdivision: _____
8. A copy of any applicable zoning ordinances in effect: ___________________________________9. Copy of Growth Policy, if applicable: On file ____________ Attached: ___________
10.Will an extension of the existing sewer main(s) be necessary to serve this subdivision?
Yes _____ No _____11.Will an extension of the existing water main(s) be necessary to serve this subdivision?
Yes _____ No _____12. How construction of the sewage disposal and water supply systems or extensions will befinanced. :____________________________ _
13.Has the governing body reviewed and approved plans to ensure adequate storm water drainageYes ____ No _____.14.Exclusion Checklist review fee, ($100) included: Yes _______ No __________
I certify that the subdivision or division is within an area covered by a growth policy pursuant to Title 76, chapter 1, MCA, or within a first-class or second-class municipality, as described in Section 7-1-4111,
MCA.
I certify that adequate storm water drainage and adequate municipal facilities will be provided for the
subdivision. I further certify that the governing body has reviewed and approved plans to ensure adequate storm water drainage.
For subdivisions subject to the Montana Subdivision and Platting Act, I certify that adequate municipal facilities for the supply of water and disposal of sewage and solid waste are available or will be provided
within the time provided in Section 76-3-507, MCA.
I further certify that I am authorized to sign this form on behalf of the governing body.
Name __________________________________ Signature ______________________________
Dept __________________________________ Title __________________________________
City _____________ Zip_______________ Phone _________________________________
Please sign and send with the $100.00 review fee to:
MONTANA DEPARTMENT OF ENVIRONMENTAL QUALITY SUBDIVISION REVIEW SECTION, PERMITTING AND COMPLIANCE DIVISION
PO BOX 200901 HELENA, MT 59620