COMMUNITY & ECONOMIC DEVELOPMENT
3130 East Main St., Springfield, OH 45503, Suite 1A | Phone: 937.521.2160 | Email: communitydevelopment@clarkcountyohio.gov
Zoning Fee must be paid at time of submission. Exception: sign application.
All fees are non-refundable and non-transferable.
** A Plot Plan must be submitted with this application **
Site Address (if no site address, enter Parcel Number)
Township
Property Owner’s Name
Owner’s Mailing Address
City State Zip
Owner’s E-Mail Address Phone Number _______ / _______ / _____________
Contractor’s Name
E-Mail Address Phone Number _______ / _______ / _____________
Give a brief description of the proposed project:
Size of the new building, structure or sign:
Height: ____________ Dimensions: ____________________ Sq. Footage: ____________
I / We,
being duly sworn certify and say that the foregoing statements in this application and information included in the
attachments and exhibits, are true and correct to the best of my/our knowledge and belief. And I/We certify that no
legal action has been entered into or is pending that would be affected by any change resulting from approval of this
request. If the Applicant is not the Property Owner, I/We certify and say that the Property Owner is aware of this
Application and concurs with its submission.
SIGNATURE: DATE: _____ / _____ / _____________
ZONING CERTIFICATE APPLICATION
For the unincorporated areas of: Bethel, Green, Harmony,
Madison, Mad River and Moorefield townships.
1/2021
