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2. Date
4. Business Location
6. Name of Business
8. Business Telephone Number
10. Business Owner Name
12. Business Manager Name
14. Email Address
16. Square Footage of Building
18. Business Type
    -- Select One --FoodIndustrialMedicalOfficeRetailSalesShort Term Rental
20. Number of Employees
22. Full Time
23. Part Time

25. Application is hereby made for certificate of zoning compliance and the statements herein are made a part thereof. It is understood and agreed by the applicant that any error, misstatement or misrepresentation of fact or expression of fact, either with or without intention on the part of the applicant, such as might, or would operate to cause the issuance of a certificate in accordance with this application, shall constitute sufficient grounds for the revocation of such certificate at any time.

27. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
29. Electronic Signature
31. *For your required Business Income Tax Questionnaire follow the link below.
    Business Tax Questionnaire
33. *For your required Life Safety Inspection, contact HHFD Fire Prevention Bureau at 937-233-1564.
35. Prior to altering or occupying a building, please contact the Montgomery County Building Regulations, 451 West Third Street, Dayton, OH; (937) 225‐4622 for a county Occupancy Permit.
Leave This Blank:


37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit

* indicates a required field