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City of Jeffersontown (City of JEffersontown)

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City of Jeffersontown – General Waiver Application 20150301 Page 1 of 3
City of Jeffersontown
Department of Permitting and Enforcement
10416 Watterson Trail
Jeffersontown, KY 40299
Phone: (502) 267-8333 Fax: (502) 267-
0547
jeffersontownky.gov
FOR OFFICE
USE ONLY
Date:
________________
General Waiver Application
Only to be used in conjunction with a Jeffersontown Board of Adjustment Conditional Use Permit or Variance
Application.
Project Information
Application is hereby made for one or more of the following waivers of the Land Development Code:
Landscape Waiver of Chapter 10, Part 2
Other: Waiver of Section ________________________
A General Waiver Application is not required for Sidewalk or Tree Canopy Waivers. If applicable, please submit a “Sidewalk Waiver
Application” or “Tree Canopy Waiver Application” instead.
Explanation of Waiver: ______________________________________________________________________
Primary Project Address: _____________________________________________________________________
Additional Address(es): ______________________________________________________________________
Primary Parcel ID: __________________________________________________________________________
Additional Parcel ID (s): _____________________________________________________________________
Proposed Use: ______________ Existing Use: __________________
Existing Zoning District: _______________________ Existing Form District: __________________________
Deed Book(s) / Page Numbers: _____________________________________
The subject property contains ______________acres. Number of Adjoining Property Owners: _____________
Has the property been the subject of a previous development proposal (e.g., rezoning, variance, appeal,
conditional use permit, minor plat, etc.)? This information can be found in the Land Development Report
(Related Cases) Yes No
If yes, please list the docket/case numbers:
Docket/Case #:______________________________ Docket/Case #:__________________________________
Docket/Case #:______________________________ Docket/Case #:__________________________________
City of Jeffersontown – General Waiver Application 20150301 Page 2 of 3
General Waiver Justification
In order to justify approval of any waiver, the Jeffersontown Board of Adjustments considers four (4) criteria.
Please answer all of the following questions. Use additional sheets if needed. A response of yes, no, or N/A is
not acceptable.
1. Will the waiver adversely affect adjacent property owners?
2. Will the waiver violate the Comprehensive Plan?
3. Is extent of waiver of the regulation the minimum necessary to afford relief to the applicate?
4. Has either (a) the applicant incorporated other design measures that exceed the minimums of the
district and compensate for non-compliance with the requirements to be waived (net beneficial
effect) or would (b) the strict application of the provisions of the regulation deprive the applicant of
the reasonable use of the land or would create an unnecessary hardship on the supplicant?
City of Jeffersontown – General Waiver Application 20150301 Page 3 of 3
Contact Information
Owner: Check if primary Contact
Name:____________________________________
Company:_________________________________
Address:__________________________________
City:______________ State:_______ Zip:_______
Primary Phone:_____________________________
Alternate Phone:____________________________
Email:____________________________________
Applicant: Check if primary Contact
Name:____________________________________
Company:_________________________________
Address:__________________________________
City:_______________ State:_______ Zip:_______
Primary Phone:_____________________________
Alternate Phone:____________________________
Email:____________________________________
Attorney: Check if primary Contact
Name:____________________________________
Company:_________________________________
Address:__________________________________
City:______________ State:_______ Zip:_______
Primary Phone:_____________________________
Alternate Phone:____________________________
Email:____________________________________
Plan prepared by: Check if primary Contact
Name:____________________________________
Company:_________________________________
Address:__________________________________
City:_______________ State:_______ Zip:_______
Primary Phone:_____________________________
Alternate Phone:____________________________
Email:____________________________________
Certification Statement: a certification statement must be submitted with any application in which the
owner(s) of the subject property is (are) a limited liability company, corporation, partnership, association,
trustee, etc., or if someone other than the owner(s) of record sign(s) the application
I,_____________________________________, in my capacity as _____________________________, hereby
Representative/authorized agent/other
certify that______________________________________________ is (are) the owner(s) of the property which
Name of LLC/corporation/partnership/association/etc.
Is the subject of this application and that I am authorized to sign this application on behalf of the owner(s).
Signature________________________________________________ Date:____________________________
I understand that knowingly providing false information on this application may result in any action taken hereon being declared null
and void. I further understand that pursuant to KRS 523.010, et seq. knowingly making a material false statement, or otherwise
providing false information with the intent to mislead a public servant in the performance of his/her duty is punishable as a Class B
misdemeanor.
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City of Jeffersontown (City of JEffersontown)

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Completed 30 June 2021

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