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City / Township Approval Form

2. 

3. City / Township Approval for Facility Applications

5. Name of Owner or Operator Applicant:*

7. Name of firm:*

9. Address1*

11. Address2

13. City*

14. State*

15. Zip*

17. Location (street address & Legal description):*

19. ** All applicants are required to obtain local land use authority i.e. City or County completion of this section of the license application.

21. Is a Conditional Use Permit (CUP) or other special zoning or land use regulation or permit required to operate this facility?

    1. Yes
    2. No

23. If YES, is the subject location/facility currently in good standing and compliant with all applicable zoning and land use permit requirements?

    1. Yes
    2. No

25. If NO, please attach the CUP or other special zoning or land use regulations required to operate the facility and identify what actions have been taken and are required to bring the facility into compliance? (Reference below)

    **Attach detailed compliance documentation and land use permit/zoning data as necessary.

27. **Identification of non-compliant zoning or land use permit conditions may be cause for Conditional License status or license denial.

29. Signature

30. Date Signed

32. Enter Name:

33. Enter Title:

35. Enter Agency:

36. Enter Phone Number:

38. Agency Address1

40. Agency Address2

42. Agency City

43. Agency State

44. Agency Zip

Leave This Blank:


45. Print Only

* indicates a required field