Request for Exemption Form - AG

Jefferson Twp. Zoning Department
28 S. Main St. POB 115
Jeffersonville, OH 43120

Certificate of Agricultural Exemption from Zoning and Possibly Building Permits

Unique Application ID

Application Date(Required)

Owner's Name(Required)

Owner's Address(Required)

Street Address Address Line 2 City State ZIP Code

Applicant's Name(Required)

Applicant's Address(Required)

Street Address Address Line 2 City State ZIP Code

Applicant's Phone(Required)

Applicant's Email(Required)

Township(Required)

Owner's Signature(Required)

Prefix First Last

Date(Required)

Reviewed by:

First Last

Upon review the Exemption from Zoning code is hereby:

Approve

Deny

Review Date

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