KRS 100.3683: Form of certificate.

The form for the certificate of land use restriction required by KRS 100.3681 shall be as

follows:

CERTIFICATE OF LAND USE RESTRICTION

1. NAME AND ADDRESS OF PROPERTY OWNER(s)

................................................. .............................................................................

................................................. .............................................................................

................................................. .............................................................................

2. ADDRESS OF PROPERTY 3. NAME OF SUBDIVISION OR

DEVELOPMENT (if applicable)

................................................. .............................................................................

................................................. .............................................................................

................................................. .............................................................................

4. TYPE OF RESTRICTION(s) (Check all that apply):

.......Zoning Map Amendment to Zone .....Conditional Zoning Condition

.......Development Plan .....Other .....................................................

specify

.......Unrecorded Subdivision Plat

.......Variance

.......Conditional Use Permit

5. NAME AND ADDRESS OF PLANNING COMMISSION, BOARD OF

ADJUSTMENT, LEGISLATIVE BODY OR FISCAL COURT WHICH

MAINTAINS THE ORIGINAL RECORDS CONTAINING THE RESTRICTION

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Signature of Completing Official

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Name and Title of Completing Official

(Type or print)