COMMUNITY & ECONOMIC DEVELOPMENT
3130 East Main St., Springfield, OH 45503, Suite 1A | Phone: 937.521.2160 | Email: communitydevelopment@clarkcountyohio.gov
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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 _______ / _______ / _____________
Agent’s Name
Agent’s E-Mail Phone Number _______ / _______ / _____________
Give a brief description of the existing use of the property:
Specify the Conditionally Permitted Use and specific section of the Zoning Regulations.
On a separate sheet, provide your responses as to how the requested Conditionally Permitted Use complies
with the appropriate Section of Chapter 7, Regulations for Conditional Uses.
Case No. BZA - ____________ - _________
Meeting Date: _____ / _____ / ___________
Fee $ ______________ Fee Paid
BS&A #
CONDITIONAL USE APPLICATION
For the unincorporated areas of: Bethel, Green, Harmony,
Madison, Mad River and Moorefield townships.
1/2021
Provide a site plan showing the following:
a. Lot lines and all existing and proposed structures on the subject property.
b. Existing and proposed access points.
c. All existing and proposed easements and rights-of-way.
d. Bodies of water, existing drainage ways and locations (if proposed to relocate).
e. Relationship to adjoining properties.
f. Locations of existing and proposed utilities.
g. Location of existing and proposed sidewalks, parking areas, and driveways.
h. Proposed treatment of existing topography, drainage ways and tree cover, as applicable.
i. Proposed landscaping and lighting plans, as applicable.
FILING FEE: A fee of $500 for Resource & Mineral Extraction cases or $175 for all other cases, which is non-refundable, must be
paid before this Conditional Use Application will be accepted. Make checks payable to “Clark County Community and Economic
Development”. A Conditional Use Application will not be accepted as officially filed, or be considered for processing, unless or until the
appropriate forms have been completed, all information (attachments/exhibits) have been submitted, and all fees have been paid in full.
OWNER/AGENT AFFIDAVIT
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: _____ / _____ / __________
NOTARY SEAL In Testimony Whereof, I have hereunto set my hand and official seal.
DATE: _____ / _____ / __________
Signature of Notary
_______________________________________
Date Commission Expires