Application For A Zoning Permit
Permit No._____ Date:______________
The undersigned hereby makes application to:
(erect)
(move in)_____________________________________________ Stories:________________
(addition) (Building Description)
1. Address:_________________________________________________________________
2. Section:_________ Township:__________ Range:__________
Block:__________ Lot:__________ Addition:__________
3. Type of Construction:__________________ Estimated Cost:_______________
(Labor & Materials)
4. Contractor: ______________________ Electrician:________________________
Plumber:______________________ Estimated time of Completion:__________________
5. Size of Building:________________________________________
6. Zoning District:___________________________
7. Building to be Used for:_________________________________________________________
8. Remarks:_____________________________________________________________________
9. Zoning Permit Fee: $10.00 (Must be submitted with Permit)
In consideration of the issuance of this permit, the applicant hereby certifies that the above statements are true and
correct, and hereby agrees to comply with the zoning regulations, and any other regulations which are in effect. If in
violation of the regulations or through misrepresentation of facts, this zoning permit then becomes null and void and
the applicant may be subject to the penalties established.
PLEASE INCLUDE A DRAWING SHOWING THE LOT SIZE, EXISTING BUILDINGS, DISTANCE FROM LOT LINES,
PROPOSED STRUCTURE AND DISTANCE BETWEEN BUILDINGS.
Applicants Name:_____________________________
(Please Print)
Address:_____________________________
______________________________
SIGNATURE:_____________________________
******************************************************************************
This permit is: APPROVED THIS ________ DAY OF _______________________
DENIED THIS _________ DAY OF _______________________
____________________________________________
ZONING ADMINISTRATOR
KEEP PERMIT ON PREMISES
APPROVED THIS___________ DAY OF______________________
SIGNATURE: _________________________________________________________
(CHAIRPERSON, VILLIAGE OF:_____________________________)