CITY OF SHELBY, RICHLAND COUNTY, OHIO
APPLICATION NO.
APPLICATION FOR A NONCONFORMITY CERTIFICATE
(File in Duplicate)
THIS APPLICATION, WHEN PROPERLY APPROVED, SHALL CONSTITUTE A
CONDITIONAL ZONING CERTIFICATE.
NAME OF APPLICANT
ADDRESS
PHONE NUMBER
LOCATION OF USE, STRUCTURE OR LOT FOR WHICH NONCONFORMITY CERTIFICATE IS SOUGHT:
ADDRESS
LOT NUMBER ZONING DISTRICT
SECTION(S) OF ORDINANCE INVOLVED
EXPLAIN IN DETAIL THE NONCONFORMITY
IF MORE SPACE IS NEEDED ATTACH SEPARATE SHEET. IF IT WILL HELP IN EXPLANATION, A SITE PLAN MAY BE INCLUDED.
Date Applicant Signature
BASED UPON THIS APPLICATION, A NONCONFORMITY CERTIFICATE IS ISSUED.
Date Zoning Inspector