REPORT#PE20 STAMP# BY ________________________________________
EXEMPT (ZONING INSPECTION ONLY) ISSUED DATE/BY
VILLAGE OF RIVER GROVE
DAVID B. GUERIN, PRESIDENT RECEIVED BY ______________________________
APPLICATION & INSPECTION FORM 01/01/2020 PRINT NAME
Owner:
Owner’s Address:
Owner’s Phone #
Building Address
Inspection Date & Time
Email: _____________________________________ PIN:
I hereby authorize the Village of River Grove’s Building Department to make an on-site
inspection of the building/premises located at the address indicated at the top of this form to
ensure compliance with all zoning regulations of the Village. I hereby also declare that this
transaction is exempt from further inspection and fees under the Village of River Grove
Ordinance #1997-06 as amended and is covered by one of the exemptions listed on the reverse side
of this form.
Claimed Exemption:
Details for exemptions claimed: (explain)
I (we) hereby declare the full actual consideration and above facts contained in this declaration to be true
and correct.
Owner/Authorized Agent Signature: Date
OFFICE USE ONLY
YES NO
____ ____ Does the residence/property comply with applicable zoning regulations regarding use, i.e. single-
family, multi-family? (VC 6-3-1) What is current zoning classification?
YOU ARE HEREBY NOTIFIED TO REMEDY THE CONDITIONS AS STATED ABOVE WITHIN 30 DAYS FROM
THE DATE OF THIS ORDER
. AN APPEAL FROM THIS ORDER MAY BE MADE WITHIN 10 DAYS FROM THE
DATE OF SERVICE
. DIRECT SUCH APPEAL FOR A HEARING BEFORE THE RIVER GROVE BUILDING
COMMISSIONER IN WRITING, 2621 THATCHER, RIVER GROVE, ILLINOIS 60171.
Signature of Inspector: Date:
