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HomeMy WebLinkAbout01-21 Application Page 12 To be completed by Planning Staff: Fee Amount Paid $ Zoning Amendment Number Anticipated PC Hearing Date Date Received Anticipated BOS Hearing Date REZONING APPLICATION FREDERICK COUNTY, VA DEPARTMENT OF PLANNING & DEVELOPMENT 1. Property Owner(s) (please attach additional page(s) if more than two owners): Name: Specific Contact Person if Other than Above: Address: Telephone: Email: Name: Specific Contact Person if Other than Above: Address: Telephone: Email: 2. Other Applicant Party (such as a contract purchaser) (please attach additional page(s) if necessary): Name: Specific Contact Person if Other than Above: Address: Telephone: Email: 3. Law firm, engineering firm, or other person, if any, serving as the primary contact person for this application: Firm Name: Specific Contact Person at Firm: Address: Telephone: Email: Please note that, if a law firm, engineering firm, or other person, other than the owner of the property, will be acting on behalf of the owner and/or executing papers on behalf of the owner in connection with the rezoning, the owner will need to execute a power of attorney form granting the firm or person such authority. Page 12 To be completed by Planning Staff: Fee Amount Paid $ Zoning Amendment Number Anticipated PC Hearing Date Date Received Anticipated BOS Hearing Date REZONING APPLICATION FREDERICK COUNTY, VA DEPARTMENT OF PLANNING & DEVELOPMENT 1. Property Owner(s) (please attach additional page(s) if more than two owners): Name: Specific Contact Person if Other than Above: Address: Telephone: Email: Name: Specific Contact Person if Other than Above: Address: Telephone: Email: 2. Other Applicant Party (such as a contract purchaser) (please attach additional page(s) if necessary): Name: Specific Contact Person if Other than Above: Address: Telephone: Email: 3. Law firm, engineering firm, or other person, if any, serving as the primary contact person for this application: Firm Name: Specific Contact Person at Firm: Address: Telephone: Email: Please note that, if a law firm, engineering firm, or other person, other than the owner of the property, will be acting on behalf of the owner and/or executing papers on behalf of the owner in connection with the rezoning, the owner will need to execute a power of attorney form granting the firm or person such authority. Page 12 To be completed by Planning Staff: Fee Amount Paid $ Zoning Amendment Number Anticipated PC Hearing Date Date Received Anticipated BOS Hearing Date REZONING APPLICATION FREDERICK COUNTY, VA DEPARTMENT OF PLANNING & DEVELOPMENT 1. Property Owner(s) (please attach additional page(s) if more than two owners): Name: Specific Contact Person if Other than Above: Address: Telephone: Email: Name: Specific Contact Person if Other than Above: Address: Telephone: Email: 2. Other Applicant Party (such as a contract purchaser) (please attach additional page(s) if necessary): Name: Specific Contact Person if Other than Above: Address: Telephone: Email: 3. Law firm, engineering firm, or other person, if any, serving as the primary contact person for this application: Firm Name: Specific Contact Person at Firm: Address: Telephone: Email: Please note that, if a law firm, engineering firm, or other person, other than the owner of the property, will be acting on behalf of the owner and/or executing papers on behalf of the owner in connection with the rezoning, the owner will need to execute a power of attorney form granting the firm or person such authority. Page 12 To be completed by Planning Staff: Fee Amount Paid $ Zoning Amendment Number Anticipated PC Hearing Date Date Received Anticipated BOS Hearing Date REZONING APPLICATION FREDERICK COUNTY, VA DEPARTMENT OF PLANNING & DEVELOPMENT 1. Property Owner(s) (please attach additional page(s) if more than two owners): Name: Specific Contact Person if Other than Above: Address: Telephone: Email: Name: Specific Contact Person if Other than Above: Address: Telephone: Email: 2. Other Applicant Party (such as a contract purchaser) (please attach additional page(s) if necessary): Name: Specific Contact Person if Other than Above: Address: Telephone: Email: 3. Law firm, engineering firm, or other person, if any, serving as the primary contact person for this application: Firm Name: Specific Contact Person at Firm: Address: Telephone: Email: Please note that, if a law firm, engineering firm, or other person, other than the owner of the property, will be acting on behalf of the owner and/or executing papers on behalf of the owner in connection with the rezoning, the owner will need to execute a power of attorney form granting the firm or person such authority. Page 12 To be completed by Planning Staff: Fee Amount Paid $ Zoning Amendment Number Anticipated PC Hearing Date Date Received Anticipated BOS Hearing Date REZONING APPLICATION FREDERICK COUNTY, VA DEPARTMENT OF PLANNING & DEVELOPMENT 1. Property Owner(s) (please attach additional page(s) if more than two owners): Name: Specific Contact Person if Other than Above: Address: Telephone: Email: Name: Specific Contact Person if Other than Above: Address: Telephone: Email: 2. Other Applicant Party (such as a contract purchaser) (please attach additional page(s) if necessary): Name: Specific Contact Person if Other than Above: Address: Telephone: Email: 3. Law firm, engineering firm, or other person, if any, serving as the primary contact person for this application: Firm Name: Specific Contact Person at Firm: Address: Telephone: Email: Please note that, if a law firm, engineering firm, or other person, other than the owner of the property, will be acting on behalf of the owner and/or executing papers on behalf of the owner in connection with the rezoning, the owner will need to execute a power of attorney form granting the firm or person such authority. Page 12 To be completed by Planning Staff: Fee Amount Paid $ Zoning Amendment Number Anticipated PC Hearing Date Date Received Anticipated BOS Hearing Date REZONING APPLICATION FREDERICK COUNTY, VA DEPARTMENT OF PLANNING & DEVELOPMENT 1. Property Owner(s) (please attach additional page(s) if more than two owners): Name: Specific Contact Person if Other than Above: Address: Telephone: Email: Name: Specific Contact Person if Other than Above: Address: Telephone: Email: 2. Other Applicant Party (such as a contract purchaser) (please attach additional page(s) if necessary): Name: Specific Contact Person if Other than Above: Address: Telephone: Email: 3. Law firm, engineering firm, or other person, if any, serving as the primary contact person for this application: Firm Name: Specific Contact Person at Firm: Address: Telephone: Email: Please note that, if a law firm, engineering firm, or other person, other than the owner of the property, will be acting on behalf of the owner and/or executing papers on behalf of the owner in connection with the rezoning, the owner will need to execute a power of attorney form granting the firm or person such authority. Page 12 To be completed by Planning Staff: Fee Amount Paid $ Zoning Amendment Number Anticipated PC Hearing Date Date Received Anticipated BOS Hearing Date REZONING APPLICATION FREDERICK COUNTY, VA DEPARTMENT OF PLANNING & DEVELOPMENT 1. Property Owner(s) (please attach additional page(s) if more than two owners): Name: Specific Contact Person if Other than Above: Address: Telephone: Email: Name: Specific Contact Person if Other than Above: Address: Telephone: Email: 2. Other Applicant Party (such as a contract purchaser) (please attach additional page(s) if necessary): Name: Specific Contact Person if Other than Above: Address: Telephone: Email: 3. Law firm, engineering firm, or other person, if any, serving as the primary contact person for this application: Firm Name: Specific Contact Person at Firm: Address: Telephone: Email: Please note that, if a law firm, engineering firm, or other person, other than the owner of the property, will be acting on behalf of the owner and/or executing papers on behalf of the owner in connection with the rezoning, the owner will need to execute a power of attorney form granting the firm or person such authority. Page 12 To be completed by Planning Staff: Fee Amount Paid $ Zoning Amendment Number Anticipated PC Hearing Date Date Received Anticipated BOS Hearing Date REZONING APPLICATION FREDERICK COUNTY, VA DEPARTMENT OF PLANNING & DEVELOPMENT 1. Property Owner(s) (please attach additional page(s) if more than two owners): Name: Specific Contact Person if Other than Above: Address: Telephone: Email: Name: Specific Contact Person if Other than Above: Address: Telephone: Email: 2. Other Applicant Party (such as a contract purchaser) (please attach additional page(s) if necessary): Name: Specific Contact Person if Other than Above: Address: Telephone: Email: 3. Law firm, engineering firm, or other person, if any, serving as the primary contact person for this application: Firm Name: Specific Contact Person at Firm: Address: Telephone: Email: Please note that, if a law firm, engineering firm, or other person, other than the owner of the property, will be acting on behalf of the owner and/or executing papers on behalf of the owner in connection with the rezoning, the owner will need to execute a power of attorney form granting the firm or person such authority. Page 12 To be completed by Planning Staff: Fee Amount Paid $ Zoning Amendment Number Anticipated PC Hearing Date Date Received Anticipated BOS Hearing Date REZONING APPLICATION FREDERICK COUNTY, VA DEPARTMENT OF PLANNING & DEVELOPMENT 1. Property Owner(s) (please attach additional page(s) if more than two owners): Name: Specific Contact Person if Other than Above: Address: Telephone: Email: Name: Specific Contact Person if Other than Above: Address: Telephone: Email: 2. Other Applicant Party (such as a contract purchaser) (please attach additional page(s) if necessary): Name: Specific Contact Person if Other than Above: Address: Telephone: Email: 3. Law firm, engineering firm, or other person, if any, serving as the primary contact person for this application: Firm Name: Specific Contact Person at Firm: Address: Telephone: Email: Please note that, if a law firm, engineering firm, or other person, other than the owner of the property, will be acting on behalf of the owner and/or executing papers on behalf of the owner in connection with the rezoning, the owner will need to execute a power of attorney form granting the firm or person such authority. Page 12 To be completed by Planning Staff: Fee Amount Paid $ Zoning Amendment Number Anticipated PC Hearing Date Date Received Anticipated BOS Hearing Date REZONING APPLICATION FREDERICK COUNTY, VA DEPARTMENT OF PLANNING & DEVELOPMENT 1. Property Owner(s) (please attach additional page(s) if more than two owners): Name: Specific Contact Person if Other than Above: Address: Telephone: Email: Name: Specific Contact Person if Other than Above: Address: Telephone: Email: 2. Other Applicant Party (such as a contract purchaser) (please attach additional page(s) if necessary): Name: Specific Contact Person if Other than Above: Address: Telephone: Email: 3. Law firm, engineering firm, or other person, if any, serving as the primary contact person for this application: Firm Name: Specific Contact Person at Firm: Address: Telephone: Email: Please note that, if a law firm, engineering firm, or other person, other than the owner of the property, will be acting on behalf of the owner and/or executing papers on behalf of the owner in connection with the rezoning, the owner will need to execute a power of attorney form granting the firm or person such authority. Page 14 6. Disclosure of real parties in interest. Virginia Code § 15.2-2289 provides that localities may by ordinance require any applicant for a zoning amendment to make complete disclosure of the equitable ownership of the real estate to be affected including, in the case of corporate ownership, the name of stockholders, officers, and directors, and in any case the names and addresses of all real parties of interest. Frederick County has, by County Code § 165-101.09, adopted such an ordinance. For each business entity that is an owner or contract purchaser of the property, please list the name and address of each person owning an interest in, or who is an officer or director of, any entity that is an owner or contract purchaser of the property (you need not indicate the amount or extent of the ownership interest). Please note that this requirement does not apply to a corporation whose stock is traded on a national or local stock exchange and having more than 500 shareholders. Please attach additional page(s) if necessary. 7. Checklist. Please check that the following items have been included with this application: □ Location Map □ Plat Depicting Metes/Bounds of Proposed Zoning □ Impact Analysis Statement □ Proffer Statement (if any) □ Agency Comments □ Fee □ Copies of Deed(s) to Property(ies) □ Tax Payment Verification □ Digital copies (pdf’s) of all submitted items