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For Of4lfe Use Only:
Case No. .;1:L: - T :.o:./l,=S
R~J
~~, ID 17 i8 lQ:)1'j ·
!~~~~~~1 ~ Zoning
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A P P LIe ~,I~~~~f r;R A
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P vi/R.AK A"'\-' MOB I L E
~E\r AND RENEloJ AL)
(Following information is to be typed or
USE
PER M I T
T 0
H 0 M E
printed)
1.
Name of Applicant: ~q rn e s. . vJ; Ll it2rn ~
(Must be owner & occupant of the Mobile Home
2.
,..
Address of Applicant 100 -r W /n f" ,clOP.. 1..J2n€. Telephone212- 59J'-
Mailing address where mobile home will be located
3.
100 -r vJ ; n yo j dJ 0 L rPn e..
*Magis terial District /v11 DL,ofH1 (4-.rJ
Tax ~1ap No.
/8 ,-IS- 0J
Subd. Name
Lot or Parcel fI-{ Blk. - Sec.
A map of this property must be attached to this application.
This map must be to scale.
4. Name of owner of property on .which mobile home will be parked
0t?mes A. ;L/..; ~rhS:
If the applicant is not the owner of the property in question,
explain. )
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.) Z 7-~
month / years
7.
Size and type of-mobile home to be parked on the above noted
I
Co 1 or&wHf!/,lJhifJridth to f.d
I
property.
Make~
Model ~t,
8.
Length 60 fct No. of Bedrooms ,2
Source of water supply ..lD-eh
Method of sewage disposal ~~~ 1~
Information obtainable from the office of
(Roqm 2.13)
the County Assessor.
No. of Bathrooms
*
~.
'....,. .
'i ."
., l
'.1"
.
e
9. 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) ~UEJf/i TT /. /Jt?atIlJJ
Tax Map No. LJ'-/j- (/) Block No.
~-O"1/ '-'WI ~J 12/ nt:~ l~A,
I
Check One Only
Address:
Owner ( ) Occupant (
Lot or Parcel No. 8
/2IUl-i JA-,
)
I do object
( )
Signature: ~~~ 1t
I do not object
( ~).
WCh?~
**********************************************************************
Name (print) VO/JA1..../J A- ~ /-I-dDti/lJ.l fiT A-Lowner ( ) Occupant ( )
Tax [\1ap No. /B- IS- (j) Block No. Lot or Parcel No. I~
/9.-/ :L s"'- f.xJ FOil,O Ill) Rr Ctf i ~ 1/3 OJ.,J ,\
"
Address:
Check One Only
I do object
( )
Signature:
I do not object
( )
$-eJL- ~11A- ~~
*******************~********************************I*****************
Name (print) /!/J/11ZcrMli-r (! 11-/ L!)(Ltfi.5-1 Owner ( v1 Occupant (J../f
Tax Map No. / g - / J--- (,) Block No. Lor or Parcel No. 9
Address: o/t) ~,l'USti,^J Sf; ~4pJ;J /iJC
S; t' IE; PJ1 Ai Ai o5.-'T /2; t,!+ , l/A- " ''2- '3 '2- J J
Check One Only
I do not object
( V)
I do object
( )
Signature: '1r;.~ f. I'-'~
Additional spaces on back of page.
(2)
~
e
.
10. THE APPLICANT 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
to: Treasurer, County of Chesterfield
B) Application fee ($45.00) is not refundable.
11. 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 respon~ibillty to contact the
Health Department and make an appointment for this inspection
(telephone .- 748~1398). The inspection form must be attached to
this applic~tion.
12. APPLICATION WILL NOT BE ACCEPTED FOR PROCESSING UNLESS OR UNTIL:
A) All questions have been ~nswered
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 BE 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.
~~/M~~
. Applicant's Signature
aW. ~
Subscribed and sworn to be~ore me this~day of _
My Commission eXPires~ It; 19:1~ .
\ " . ~ . '.......
, 197~.
(Page 4)
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