BOARD OF ADJUSTMENT - APPLICATION FOR

CONDITIONAL USE PERMIT

Application #

The undersigned requests a Conditional Use Permit as specified below. Should this application be approved, it is understood that it shall only authorize that particular use described in this application and any conditions or safe guards required by the Board. In any case where a conditional use permit has not been exercised within the time limit set by the Board, or within one (1) year, if specified time limit has not been set, such conditional use permit shall not revert to its original designation unless there is a public hearing. Granting of a conditional use permit does not exempt the applicant from complying with all of the requirements of building, housing, and other regulations. The applicant understands that the administrative official is authorized to review all conditional use permits granted by the Board, to inspect the land or structure where the conditional use is located in order to ascertain compliance with all conditions attached by the Board to the conditional use permit.

1. NAME OF OWNER

MAILING ADDRESS

PHONE NUMBER: HOME BUSINESS

2. LOCATION DESCRIPTION: PROPERTY ADDRESS

I. SUBDIVISION NAME II. LOT NO. & BLOCK

III. DEED BOOK & PAGE NO.

( If not in a platted subdivision, attach a legal description - If platted, attached copy of plat)

3. EXISTING USE

4. PROPERTY PRESENTLY ZONED AS ORDINANCE NO.:

5. DESCRIPTION OF CONDITIONAL USE

6. APPLICANT SHALL FURNISH TO THE BOARD THE NAME AND ADDRESS OF ANY OWNER OF EACH PARCEL OF PROPERTY THAT ADJOINS ABOVE SAID PROPERTY AND ALL REQUIREMENTS AS SET FORTH IN 401.B OF THE ZONING ORDINANCE SHALL APPLY.

7. ATTACH A WRITTEN STATEMENT WHICH SATISFIES THE FOLLOWING TWO (2) REQUIREMENTS:

a) A statement of the specific reasons the Board of Adjustment is justified in issuing the permit.

b) A statement of suggested conditions which must be met in order for the use to be permitted.

8. PLEASE ATTACH A SITE PLAN FOR THE PROPOSED USE SHOWING THE LOCATION OF BUILDING, PARKING AND LOADING AREAS, TRAFFIC ACCESS AND CIRCULATION DRIVES, OPEN SPACE, LANDSCAPING, UTILITIES, SIGNS, YARDS, AND REFUSE AND SERVICE AREAS.

DATE OWNER’S SIGNATURE

FOR OFFICIAL USE ONLY

DECISION OF BOARD OF ADJUSTMENT : APPROVED DENIED

If approved, the following conditions and safeguards were prescribed:

If denied, reason for denial: Versailles-Midway-Woodford County

Board of Adjustment

Date Chairman

DATE OF NOTICE TO PARTIES IN INTEREST

DATE OF NOTICE TO NEWSPAPER

DATE OF PUBLIC HEARING

FEES PAID: $ (conditional use permit)

$ (adj. prop. letters)

Permanently Satisfied Date $ (co. clerk recording)

Zoning Administrator Date Filed