APPLICATION FOR A NEW RESIDENTIAL CARE FACILITY

Name of Facility:
Location Address:
City:	State:	NC	Zip:
Facility Phone #:	Email:
Owner of Business:
Mailing Address:
City:	State:	Zip:
Contact Phone #:	Email:
Please specify the following:
Sewer:	Public/Municipal	On-site Wastewater System
Water:	Public/Municipal	Private Water Supply
*Facilities connected to an on-site wastewater system may require an existing systems inspection.
Number of Residents:
A “Resident" means a person, other than the administrator, his or her immediate family, and residential care facility employees, who is residing in a residential care facility.
Directions from Shelby:

You will be responsible for obtaining approval from appropriate zoning and building inspection departments. Their numbers are included below to assist you.

ZONING / BUILDING INSPECTION	FIRE MARSHALLS

Shelby 704-484-6805	704-484-6816

Kings Mountain 704-734-4599	704-734-0555

Cleveland County 980-484-4975/4997	980-481-4841

If your business will be located in any jurisdiction other than those listed above, please check with your city manager and/or town hall for permitting assistance.

Signature of Applicant:	Date:

APPLICATIONS CAN BE SUBMITTED IN PERSON OR BY MAIL TO:

Cleveland County Permits Office

1333 Fallston Road

Rev. 5/24 Shelby, NC 28150