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2. First Name
3. Last Name
5. Phone Number
7. Email Address
9. Project Address
   Provide the address where the structure will be located.
11. Type of Proposed Structure*
    -- Select One --Accessory BuildingAlterationCarportDumpster (Temporary)Garage - AttachedHot TubPatio EnclusurePatio Cover- FrontPatio Cover - SidePatio Cover - RearPergolaRoom AdditionStorage Container (Tempoary)Swimming PoolTentTower - Residential Use

    *Note: Structures over 200 sq. ft. and/or with a foundation also must have site and construction plans, drawn to scale, submitted to Montgomery County Building Regulations, phone 937-225-4622.

13. Definition of Structure Types and Location Requirements
    Definitions
15. 
17. Structure Location*

    *Note on the above sketches what is defined as the rear yard. Describe above where on the property the structure will be located.  All Accessory Buildings, Swimming Pools, and Hot Tubs must be located in your Rear Yard.

19. Structure Length*
20. Width*
21. Height*
22. Total Square Footage*
24. Distance From Property Lines - Front Yard*
25. Side Yard*
26. Side Yard*
27. Rear Yard*
29. Application is hereby made for zoning certificate, 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 permit in accordance with this application, shall constitute sufficient ground for the revocation such permit at any time. The applicant is responsible for Third party and/or in-house professional costs incurred by the City for legal and engineering services. The fee schedule for legal and engineering services is available upon request. (Ordinance 87-O-231, Effective 4/2/87) (Ordinance 87-0-272, Effective 11/21/87)
30. Online Payment

    After you submit this form, you will automatically be redirected to the online payments page.

32. 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.
34. Electronic Signature
36. Office/Staff Use Only
38. Amount Paid
39. Payment Type
40. Rec'd By
41. Receipt #
43. Permit Number
44. Authorized Signature
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46. 1. Receive an email copy of this form.
47. Email address

    This field is not part of the form submission.

48. Submit

* indicates a required field