G:\BUILDING REGS\Reference Resources\ZMiscellaneous\Res Bldg Appeals\Masters\Residential Board of Building Appeals App.doc
RESIDENTIAL BOARD OF APPEALS
APPLICATION FOR ONE, TWO AND THREE FAMILY DWELLING
The required filing fee of $200 made payable to Clark County Community & Economic Development shall be paid prior to
processing. All data requested in this application must be submitted in order to accurately review the proposed case.
Incomplete date may result in the application being rejected. This application and all required information must be typed
or printed legibly in pen. An application for appeals in response to Adjudication Orders shall be made by the owner or the
owner’s documented representative. Submit application to Clark County Community & Economic Development,
Springview Government Center, 3130 East Main Street, Suite 1A, Springfield, Ohio 45505.
1. Owner: ______________________________________________________________________________________
2. Owner Address: _______________________________________________________________________________
3. City / State / Zip: _______________________________________________________________________________
4. Phone: Residence ______________________________ Mobile: _________________________________________
5. Address of project: _____________________________________________________________________________
6. Applicant’s Name: _____________________________________________________________________________
7. Applicant’s Address:____________________________________________________________________________
8. Applicant’s Phone Number: ______________ Mobile: _____________ Email: ______________________________
Application is hereby made for the relief from the following check all that apply:
Code has been incorrectly interpreted.
Provisions of the code do not apply.
Requirements of the code are satisfied by other means.
Application is hereby made from relief from the following section(s): ________________________________________
Please explain your arguments for the appeal:_________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Applicant Signature ________________________________________________ Date _____________________
Attach a copy of Adjudication Order and/or Notice of Violation. The application must be placed on file with the Building
Official within thirty (30) days of the mailing of the Adjudication Order or Notice of Violation. Applicant shall be notified of
the date, time and place of the hearing, which will be no more than thirty (30) days after receipt of appeal. It is
recommended that the owner be present at the hearing. Applicant will be notified in writing of the decision of the Board.
Office Use Only
Date Received: _____________________________ Appeal Case No.:____________________
Received by: _______________________ Scheduled Meeting Date: ________________________
Approved: Yes: No:
