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City of Jeffersontown (City of JEffersontown)

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City of Jeffersontown – Variance Application & Checklist 20150301 Page 1 of 8
Variance Application
Fee
See fee schedule.
The purpose of this Variance is (i.e.: side yard encroachm
ent, private yard):
The section of the
LDC that the Variance is being requested for: ______________________________________________
Statement of Cost for Project: Please provide an estimated cost for this project
Project cost: $__________________ Projected Infrastructure Improvement Cost (if applicable): $___________________
Name of the Project: _________________________________________________________________________________
Property Address:____________________________________________________Parcel ID:_______________________
Contact Information
Owner Information and signature(s): Required for all applications. Application will not be accepted without it.
Please add additional sheets as needed.
Any additional required reviews or approvals must be obtained by the owner or owner’s representative prior to the
issuance of any building permit. It is the owner or owner’s representative responsibility to verify all Jeffersontown Land
Development Code requirements are being followed.
Please attach any additional owner or contact information pages to this application. The Certification Statement must be
completed if someone other than an individual owner will be representing this case at Permitting, Planning and
Enforcement (i.e. signing authority for a company, Surveyor, Engineer, etc.).
Property Owner Information:
Name:_________________________________________
Signature:______________________________________
Address:_______________________________________
City:___________________ State:______ Zip:________
Primary Phone:__________________________________
Alternate Phone:_________________________________
E-Mail:________________________________________
Property Owner Information:
Name:_________________________________________
Signature:______________________________________
Address:_______________________________________
City:___________________ State:______ Zip:________
Primary Phone:__________________________________
Alternate Phone:_________________________________
E-Mail:________________________________________
City of Jeffersontown
Department of Permitting, Planning and Enforcement
10416 Watterson Trail
Jeffersontown, KY 40299
Phone: (502) 267-8333 Fax: (502) 267-
0547
jeffersontownky.gov
Case No._________________
Intake Staff: _____________
Date:____________________
Fee:_____________________
City of Jeffersontown – Variance Application & Checklist 20150301 Page 2 of 8
Primary Contact Information:
Name:_________________________________________
Signature:______________________________________
Address:_______________________________________
City:___________________ State:______ Zip:________
Primary Phone:__________________________________
Alternate Phone:_________________________________
E-Mail:________________________________________
Secondary Contact Information:
Name:_________________________________________
Signature:______________________________________
Address:_______________________________________
City:___________________ State:______ Zip:________
Primary Phone:__________________________________
Alternate Phone:_________________________________
E-Mail:________________________________________
Application Detail
Related Cases: If the property, or any portion thereof, has been the subject of a previous proposal in this office, please
list the docket / case number(s). Examples include but are not limited to: Waivers, CUP, RDDP.
Docket / Case #:_________________________________
Docket / Case #:_________________________________
Docket / Case #:_________________________________
Docket / Case #:_________________________________
The Subject property contains square feet / acres________________ Number of APO’s:___________________________
Deed Book / Page:___________________________________________________________________________________
Existing Use:_____________________________________ Proposed Use:_____________________________________
Please use the Development Information Sheet (DI) to answer the following questions.
Existing Zoning District:__________________________
Fire Protection District:___________________________
Existing Form District:____________________________
Council District:_________________________________
Supplemental Information
In order to justify approval of any Variance, the Board considers four criteria. Please answer all of the following items.
(Use additional sheets if needed). All questions must be answered. A response of yes, no and not applicable (N/A) is
not acceptable.
1. Reasons that the granting of the variance:
a. Will not adversely affect the public health, safety or welfare.
City of Jeffersontown
Department of Permitting, Planning and Enforcement
10416 Watterson Trail
Jeffersontown, KY 40299
Phone: (502) 267-8333 Fax: (502) 267-
0547
jeffersontownky.gov
Case No._________________
Intake Staff: _____________
Date:____________________
Fee:_____________________
City of Jeffersontown – Variance Application & Checklist 20150301 Page 3 of 8
b. Will not alter the essential character of the general vicinity.
c. Will not cause a hazard or a nuisance to the public.
d. Will not allow an u
nreasonable circumvention of the requirements of the zoning regulations.
2. Additional Consideration.
a. W
hether the variance arises from special circumstances, which do no t generally apply to land in the
general vicinity; (Please specify / identify)
b. Whether the strict application of the provisions of the regulation would deprive the applicant of the
reasonable use of the land or would create an unnecessary hardship.
c. Whether the circumstances are the result of actions of the applicant taken subsequent to the adoption of
the regulation which relief is sought.
City of Jeffersontown
Department of Permitting, Planning and Enforcement
10416 Watterson Trail
Jeffersontown, KY 40299
Phone: (502) 267-8333 Fax: (502) 267-
0547
jeffersontownky.gov
Case No._________________
Intake Staff: _____________
Date:____________________
Fee:_____________________
City of Jeffersontown – Variance Application & Checklist 20150301 Page 4 of 8
Certification Statement: (Please fill out applicable section(s).)
Section 1:
Authorized Agent of a: corporation, limited liability company, partnership, association, trustee, etc.
I hereby certify that _______________________________________________________________________ is the owner
corporation / limited liability company / partnership / association / trustee / etc.
of the property located at _____________________________________________________________________________
which is the subject of this application, and that I, _________________________________________________________
Owner / Representative / Authorized Agent
in my capacity as ____________________________________________________, am authorized to sign this application
on behalf of the owners.
Owner / Authorized Representative Signature:_____________________________________________________________
Print Name: _______________________________________________________________________________________
Title:______________________________________________________ Date:___________________________________
Section 2: Homeowner, Authorized Agent or Representative authorization
I, in my capacity as Owner Representative Authorized Agent (anyone other than the owner fill out section 1)
Check one
of the property located at _____________________________________________________________________________
which is the subject of this application, and that I, _________________________________________________________
Authorized Representative
am authorized to sign on behalf of the owner.
Owner:____________________________________________________________________________________________
Print Name:________________________________________________________________________________________
Authorized Representative Signature:____________________________________________________________________
Phone:____________________________________________ E-mail:_________________________________________
City of Jeffersontown
Department of Permitting, Planning and Enforcement
10416 Watterson Trail
Jeffersontown, KY 40299
Phone: (502) 267-8333 Fax: (502) 267-
0547
jeffersontownky.gov
Case No._________________
Intake Staff: _____________
Date:____________________
Fee:_____________________
I understand that knowingly providing false information on this application may result in any action taken being here on 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.
I understand that knowingly providing false information on this application may result in any action taken being here on 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.
City of Jeffersontown – Variance Application & Checklist 20150301 Page 5 of 8
Non-Public Hearing Variance Affidavit for the Subject Property Owner(s)
Qualifications for a Non-Public Hearing include:
1. Residential, non-corner parcels only.
2. All adjoining property owners must sign this affidavit. This includes all owners listed on the deed.
3. For each adjoining property owner that is held by a company, corporation, trust, etc. there must be a
Certification Statement included with the affidavit.
4. All supporting documentation listed in the checklist must be included with the application.
Date:________________________________________________
I (We),____________________________________________________________________________________________
Owner(s) of the subject property under Case Number _____________ states as follows: It is hereby requested that the
application for variance under Case Number _____________ be considered by the Board in open executive session
without holding a public hearing on the proposal.
The signatures of all adjoining property owners required by the Board of Adjustment have been submitted to the Board so
that the variance may be acted upon without a public hearing.
________________________________________________________
Signature of Owner
________________________________________________________
Print Name
________________________________________________________
Signature of Owner
________________________________________________________
Print Name
City of Jeffersontown
Department of Permitting, Planning and Enforcement
10416 Watterson Trail
Jeffersontown, KY 40299
Phone: (502) 267-8333 Fax: (502) 267-
0547
jeffersontownky.gov
Case No._________________
Intake Staff: _____________
Date:____________________
Fee:_____________________
City of Jeffersontown – Variance Application & Checklist 20150301 Page 6 of 8
Non-Public Hearing Variance Affidavit for the Subject Property Owner(s)
Date:________________________________________________
We have seen a drawing of the proposed (garage, addition)__________________________________________________
To be constructed at (Address):________________________________________________________________________
__________________________________________________________________________________________________
As owners of the properly adjacent to the above address, we give our consent and do no t object to the planned
construction or to the variance that will be required. PLEASE NOTE: If the property is in joint ownership, all owners
must sign, or if there is a POA, deceased or extenuating circumstances please indicate on the signature line.
1. Print Name & Signature:__________________________________________________________________________
Signature of Owner
1. Print Name & Signature:__________________________________________________________________________
Signature of Owner
Address:___________________________________________________________________________________________
2. Print Name & Signature:__________________________________________________________________________
Signature of Owner
2. Print Name & Signature:__________________________________________________________________________
Signature of Owner
Address:___________________________________________________________________________________________
3. Print Name & Signature:__________________________________________________________________________
Signature of Owner
3. Print Name & Signature:__________________________________________________________________________
Signature of Owner
Address:___________________________________________________________________________________________
4. Print Name & Signature:__________________________________________________________________________
Signature of Owner
4. Print Name & Signature:__________________________________________________________________________
Signature of Owner
Address:___________________________________________________________________________________________
5. Print Name & Signature:__________________________________________________________________________
Signature of Owner
5. Print Name & Signature:__________________________________________________________________________
Signature of Owner
Address:___________________________________________________________________________________________
6. Print Name & Signature:__________________________________________________________________________
Signature of Owner
6. Print Name & Signature:__________________________________________________________________________
Signature of Owner
Address:___________________________________________________________________________________________
7. Print Name & Signature:__________________________________________________________________________
Signature of Owner
7. Print Name & Signature:__________________________________________________________________________
Signature of Owner
Address:___________________________________________________________________________________________
For additional signatures please attach another page.
City of Jeffersontown – Variance Application & Checklist 20150301 Page 7 of 8
Checklist
Requirements for all Submittals
1. Completed Application. All blanks must be filled in. The Owner’s information and signature are required.
2. Completed Supplemental Information Sheet
3. Development Information (DI) Sheet (This can be obtained from LOJIC)
4. One (1) copy of the current deed (May be obtained from Jefferson County Clerk)
5. Legal Description on separate 8 1/2” x 11” sheet of paper, if changed from original submittal.
6. One (1) copy of the 1
st
tier Adjoining Property Owner mailing labels, including all owners, applications and
contacts. Please use the sheet style peel off sticky labels. (May be obtained from PVA)
7. One (1) photo copy mailing labels
Requirements for Non-Public Hearing Only (residential only and non-corner lots)
8. Non-hearing affidavits form
9. Photographs of subject area from all angles
10. Certification Statement is required if any of the adjoining property is owned by a corporation, limited liability
company, partnership, association, trustee, etc.
Supplemental Information
11. Certification Statement if the property is owned by a corporation, limited liability company, partnership,
association, trustee, etc. or the Homeowner has a representative.
12. Supporting Documents (such as adjoining property photographs, photographs of intersections, written affidavits)
13. Copy of Refusal letter from citing official. Required if a STOP WORK ORDER or CITATION has been
received.
14. If the proposed structure encroaches into an easement (MSD, LG&E, or Bell South), then the applicant must
submit written documentation from the utility company indicating approval for the encroachment.
Site Plan Requirement
15. One (1) Elevation drawing for new construction (including home additions and garage additions)
16. Five (5) copies of the drawing of the property with the following requirements. See Site Plan Example
a. A Plan drawn to a reasonable scale [engineer’s (1”= 20’)]
b. Vicinity map that shows the distance from the property to the nearest intersecting street
c. North arrow
d. Street name(s) abutting the site. Property dimensions
e. Building limit line
f. Electric, telephone, drainage easements with dimensions
g. Existing and proposed structures with dimensions and distance from property lines
h. Highlight (in yellow) the location of the variances.
City of Jeffersontown
Department of Permitting, Planning and Enforcement
10416 Watterson Trail
Jeffersontown, KY 40299
Phone: (502) 267-8333 Fax: (502) 267-
0547
jeffersontownky.gov
City of Jeffersontown – Variance Application & Checklist 20150301 Page 8 of 8
Site Plan Example (Example only, not drawn to true scale.)
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Completed 30 June 2021

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