75S037For Of"h.e Use Only:
Case No.. ~"~0~. 7
Zoning ~-- 7,,
APPLICATION FOR A USE PERMIT
TO PA R~ MOBILE HOME
F't NR~ AND RENEWAL) .
ollowing info--ion is to be typed or printed)
Mailin~ add~ess where obile ho~ ~1i be zocateS'
*Magisterial District/~/y~c./~ L Tax Map Ne. /.¢z:~_~.f/~_~_)
A map of this property must be attached to this application.
This map must be to scale.
Name of owner of property on which mobile home will be parked'
-(If thc ~ppzican~ is n6t th'e owfiSr 0~ th~e'p O¢~rtY in-quest-ion,
explain. ) r -
5. If mobile home will remain unoccupied, explain
6. Time requested for mobile home to remain at site (use permit
granted for a maximum of two years only.)
m°n~'hs "?- y~a~'
?. Size and type of mobile home to be parked on the above noted
property. Make . _Model Color Width
Length,, No. of Bedrooms No. of Bathrooms
8. Source of water supply
Method of sewage disposal ~z~-~,~D,/~c~C
U / ~
~ Info~a~ion ob~ainable f~om the office of ~he gounty Assesso~
(Eoom 213)
Information, addresses, and signatures of all property owners,occupants
who are adjacent to the parcel on which the mobile home be located must
be provided in the spaces below.
We., the undersigned owners and occupants of the adjadent
property to the property on which a mobile home is proposed to
be located, hereby certify that we do or do not object to the
granting~of a Use Permit to park a mobile home on the property
described in this petition.
Information available from the office of the County Assessor (Room 213).
Name (print). ~ e~ . ~$
· a~ ~ ~o._,,..~?_ ~ (,~)
Address: ~~
Block No.
Owner (~ Occupant ( )
~.. Lot or Parcel No. ~
Check One Only
I do object I do not object
Name (print)~o~dos~,~ul~£.w~s~ ~ ~o~$~, Owner (~ Occupant ( )
~ax ~ap ~o./~._/,~f~) ,~look ~o. ~- ~ot or Parcel .o. ~
Check One Only
I do object I do not ob~ect
( ) ( ~
Name (print)_~~/~.~me0~ ~ ~,.~.~. Owner (~.)~ Occupant ( )
Check One Only
I do object I do not object
( ) (
Additional spaces on back of page.
(2)
?a× ~ap No./?/?- /,/
Cheek One Only
I do object I do no~ object
Signature:
Name (print)~././4~A~. ,~,/...~g .~/ ¢ Z"~~ Owner (~-~ Occupant ( )
Tax ~a~ No.
Address:
Check One Only
I do object I do not object
Signa ute: ~ ..... ~ ....
************************************************************************
Tax Map No. ,/~_~/~--,/,~) Block NO. ~
Address:
Owner (~ Occupant (
E~o4y--o~ Parcel No. /
I do object
( )
Signature:
Check One Only
! do not Object
( )
Name (print)
Tax Map No,
Address:
Block No.
Owner ( ) Occupant (
Lot or Parcel No,
I do object
( )
Signature:
Check One Only
I do not object
(
(3)
10.
ll.
12,
THE A.PPLICANT HEREWITH DEpOsITS THE SUM-OF FORTY-FIVE DOLLARS
($45,00) TO BE ATTACHED TO THIS APPLICATION TO ASSIST IN
DEFRAYING THE COST OF PROCESSING THE SAME,
A) Check or money order must be made payable.
B)
to: Treasurer, County of Chesterfield
Application fee ($45.00) is not refundable.
The Chesterfield County Health Department must make an inspection
of the proposed or existln~ mobile home location site (both new &
renewal). It is the applicant's responsibility to contact the
Health Department and make an appointment for this inspection
(telephone .~ 745-1398). The inspection form must be attached to
this application.
APPLICATION WILL NOT BE ACCEPTED FOR PROCESSING UNLESS OR UNTIL:
A) All questions have been answered
B) Location map or plat is attached
C) Health Department inspection form attached
D) Application is signed and notarized~
THE APPLICANT AND/OR HIS AGENT MUST RE PRESENT AT THE BOARD HEARING.
I/We hereby certify that all of the above statements and the statements
contained in any exhibits transmitted herewith are true.
Signature
Subscribed and sworn to before me this Iq day of ~.~o~,,t.
My Commission expires ~D~ovea~wOJ~, ~j ,/~,~.~,
( Not ar;~ Public)
(Page