Non-Conforming Certificate Application

Property Owner First Name *

Property Owner Last Name *

Phone

Email *

Tax ID # *

Address *

City *

State *
AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip *

Business Name *

Business Type *

Business Hours *

Operation Activities *

I hereby certify that I am the renter/owner/or authorized agent of the above-mentioned property and all the information listed above is true and correct to the best of my knowledge.
Applicant Signature: