APPLICATION TO KEEP CHICKENS

(04/2014)

City of Goshen Police Department • Code Enforcement
111 East Jefferson Street • Goshen, Indiana 46528

Applicant name(s): ________________________________________________________ Phone: ___________________________
Address where chickens will be kept: _______________________________________________________________________________________
Is the address where chickens will be kept zoned A-1, agricultural district?

G Yes

G No

If yes, then Ordinance 4773 entitled Keeping Chickens does not apply. Please consult the Planning and Zoning Department
at 534-3600 if you wish to keep chickens.
The address where chickens will be kept is an occupied:

G single-family dwelling

G two-family dwelling

If the address is a two-family dwelling, does the owner of the real estate reside in one of the two units?

G Yes

Is the applicant the owner of the real estate?

G Yes

G No

G No

If no, provide the name and address of the owner of the real estate:
Owner name: ___________________________________________________________
______________________________________________________
Owner address: __________________________________________________________________________________________________________
Have you included with this application the written approval of each adjoining real estate owner?

G Yes

G No

By submitting this application and as a condition of receiving a permit, I agree that I will keep, possess, or maintain chickens
at the above address in accordance with all provisions set forth in Goshen City Ordinance 4773 entitled Keeping Chickens.

Signature: _______________________________________________________________ Date: ___________________________

Signature: _______________________________________________________________ Date: ___________________________

FOR OFFICE USE ONLY
Zoning of address where chickens will be kept verified?

G Yes

Written approval of each adjoining real estate owner submitted?
Accuracy of each adjoining real estate owner confirmed?
$25 registration fee submitted?

G Yes

G Yes

G No
G Yes

G No

G No

G No

Permit application to keep chickens approved?

G Yes

G No

Approved by: _____________________________________________________________ Date: ___________________________________
Permit number: _______________________________
Issuance date: ________________________________

ADJOINING REAL ESTATE OWNER CONSENT FORM

Applicant name(s): ____________________________________________________________________________________
Address where chickens will be kept: _______________________________________________________________________________________

My neighbor at the above address desires to keep, possess, or maintain chickens at this location in accordance with
Goshen City Ordinance 4773 entitled Keeping Chickens.
I understand that my written approval is required since my real estate is immediately adjacent to the real estate parcel
that will be keeping chickens.
I approve my neighbor’s application to keep, possess, or maintain chickens at this location.

Print name and address: ______________________________________________________________
______________________________
Signature: _______________________________________________________________ Date: ________________________________

Print name and address: ______________________________________________________________
______________________________
Signature: _______________________________________________________________ Date: ________________________________

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