75SR223BOARD OF SUPERVISORS
CHESTERFIELD COUNTY
CHESTERFI ELD, VA.
For Office Use Only:
Case No. ,7~)"S~ Z~'
Fee Receipt No. ~¢1
~ RECE~;[,D~ ~t~c~o. ~o~
~- CHEST[ '= ~ COUHTY~/ (N~ ~ RE~);
~1~, ~m,"2~~llowing infomation~tt~ed or printed)
(Must be o~er & occupant of%the Mobile Hme)
2. ~dress of Applicant
Su~. N~o ~t/Parcel / Blk. Sec.
A map of this property must be attached to this application°
This map must be to scale.
5. Name~of owner of property on which mobile home will be parked
("i .e applicant is'not wner of the pr6perty in question,
explain.) ~.,, '~.N~-N-%~ ~%.0~ ~ ~ \o.~ei
~ ~,',~ ~ 1 o,~,'~. ~*r~.~ ,~,, ~,~ ~~-
6. If mObile h~e will ~emain un~cupied, explai~ ..... - . '
7. Time requested for mobile home to remain at site (use permit
granted for a maximum of two years only.)
months / years
8. Size and type of mobile home to be parked on the above noted
e
property. Make~o%a~,x,,~rModel
Length ~0! No. of Bedrooms ,,\
Source of water supply
Color c~v~ /t.o%.,.~-~, Width
-~3 \1
NO. of Bathrooms ~
,,
Method of sewage disposal
Information obtainable from the office of the County Assessor.
(Room 213)
10.
11.
12.
(name of public '~oad) ,
Are there any other mobile homes parked on this property? /
(Yes or no)
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 adjacent
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) 1/f/~3~4 ~':P~ er (~) Occupant { )
Tax Map No. /~ ~ ~~ Block No. Lot or Parcel No. ~
~dress:
~eck One Only
I do object I do ng.t object
( ) (~ )
Name (print)v ~/]. /:/d~'''~ Owner ()Occupant()
Tax Map No. 1~'"'-~,'~ Bl~ck,_No. Lot or..~cel No. ~
Chg~k One Only
I do objec~ ~/ I do npt ~bject
Signature: //~~~
*************--********************************************
Check One Only
I do object I do not object
S tgnat~e:
(2)
Name (print)
Tax Map No.
Address:
I do object
Signature:( )~~i~
Check ~ne Only
I do not object ~
(~) "~
Name (print)
Owner ( ) Occupant ( )
Tax Map No.
Block No.
Lot or Parcel No.
Address:
I do object
( )
Signature:
Check One Only
I do not object
( )
Name (print)
Owner ( ) Occupant ( )
Tax Map No.
Block No.
Lot or Parcel No.
Address:
I do object
( )
Check One Only
I do not object
( )
Signature:
***********************************************************************
Name (print) Owner ( ) Occupant ( )
Tax Map No. Block NCo Lot or Parcel No.
Address:
Check One 9Dl~y
I do object I do not object
( ) ( )
Signature:
Additional spaces on back of page.
(3)
13o THE APPLICANT HEREWITH DEPOSITS THE SUM OF FIFTY DOLLARS $50.00)
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.
Treasurer, County of Chesterfield
B) Application fee ($50°00) is not refundable°
14.
The CheSterfield County Health Department must make an inspection
of the proposed or existing 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
~(teleDhone - 748-1398). The inspection form must be attached to
this application.
15. APPLICATION WILL NOT BE ACCEPTED FOR PROCESSING UNLESS OR UNTIL:
A) Ail questions have been answered
B) Location map or plat is attached
C) Health Department inspection fcrm attached
D) Application is signed and notarized.
THE APPLICANT AND/OR HIS AGENT MUST BE PRESENT AT THE BOARD MEETING°
I/We hereby certify that all of the above statements and the statements
contained in any exhibits transmitted herewith are true.
\ Applic~a~a~/s Signature
Subscribed and sworn to before me this.....~..~., day of
My Commission expires ~ 9c~ /%~%
(4)
(Notary Public)