Rev. 05/2019 Land Use Permit Application
LAND USE PERMIT
LUP-A Land Use Permit Application
APPLICATION is hereby made for permit as shown on the accompanying plan or sketch and as described below. Said activity(s) will be done under and in accordance with
the rules and regulations of the Council of the Town of Berryville, in so far as said rules are applicable thereto and any agreement between the parties herein before referred
to. Where applicable agreements may be attached and made a part of the permit assembly including any cost responsibilities covering work under permit. Applicant agrees to
maintain work in a manner as approved upon its completion. Applicant also hereby agrees and is bound and held responsible to the owner for any and all damages to any
other installations already in place as a result of work covered by resulting permit. Applicants to whom permits are issued shall at all times indemnify and save harmless the
Town of Berryville Council members, the Town and all Town employees, agents, and offices, from responsibility, damage, or liability arising from the exercise of the privileges
granted in such permit to the extent allowed by law. In consideration of the issuance of a permit the applicant agrees to waive for itself, successors in interest or assigns any
entitlements it may otherwise have or have hereafter under the Uniform Relocation and Assistant Act of 1972 as amended in event the Town or its successor, chooses to
exercise its acknowledged right to demand or cause the removal of any or all fixtures, personality of whatever kind or description that may hereafter be located, should this
application be approved.
Type or print clearly
A
pplicant Driver’s license or Tax ID No. _________________________ Contact Name ____________________________________________
Owner Name ________________________________________________ E-mail Address __________________________________________
Address ____________________________________________________ Telephone Number ( ______ ) _______ - ____________
City ________________________State ______Zip Code_____________ Emergency Telephone Number ( ______ ) _______ - ________
Fax Number ( ______ ) _______ - __________
Agent Driver’s license or Tax ID No. ____________________________ Contact Name ___________________________________________
Agent Name ________________________________________________ E-mail Address __________________________________________
Address ____________________________________________________ Telephone Number ( ______ ) _______ - ____________
City ________________________State ______Zip Code_____________ Emergency Telephone Number ( ______ ) _______ - _______
Fax Number ( _____ ) _______-__________
P
ermit Term Requested ________ Fees Enclosed $____________ Check Number ____________
Money Order __________ Other __________ Estimated cost of work to be performed on Town of Berryville Right of Way $____________
Surety Information: Surety Posted by: Owner [ ] Agent [ ]
Surety Refund to: Owner [ ] Agent [ ]
Surety Waived [ ]
Amount of Surety $ ____________________ Obligation Amount $_________________ Check # ________________
Surety Company Name ____________________________________________ Bond #__________________________
[ ] LUP-CS CASH SURETY AFFIDAVIT PROVIDED FOR CASH SURETY
Applicant has provided proof of the following requirements in accordance as defined in §2.2-1151.1 of the Code of Virginia
(1) The utility company has registered as an operator with the appropriate notification center.
(2) Attached is a notarized affidavit, stating that the utility owner has notified the commercial and residential developer, owner of commercial or multifamily real estate,
or local government entities with a property interest in any parcel of land located adjacent to the property over which the land use is being requested, that
application for the permit has been made.
Request permission to perform the following activity(s): ________________________________________________________________________
_________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________as per attached plans.
Location: [ ] Town of __________________________ Route No. ________ Street Name ________________________________________________
Latitude _________________ Longitude__________________ Tax Map Number _______________________ Applicant Job No.__________________
Between Route No. _________ Street Name _________________________ and Route No._________ Street Name ___________________________
[
] IF APPLICABLE, I AGREE TO PAY THE FULL SALARY AND EXPENSES OF A TOWN ASSIGNED INSPECTOR IN CONJUNCTION WITH
ACTIVITIES AUTHORIZED UNDER THE AUSPICES OF A TOWN OF BERRYVILLE LAND USE PERMIT
S
ignature of Applicant: ________________________________________________ Title __________________________ Date ___________________
Signature of Agent: _________________________________________________ Title __________________________ Date __________________
All applicable items on this form must be completed to avoid delay in processing the issuance of a Town of Berryville Land Use Permit.
Prepayment required with remittance payable to Town of Berryville.
TOWN OF BERRYVILLE USE ONLY
R
eceipt is hereby acknowledged for: CHECK No. ____________ MONEY ORDER No. _________________
In the Amount of $ _________________________ for PERMIT FEE $ _______________________ CASH SURETY $ _______________________
Authorized Town Signature: ____________________________________________________ Date: _______________________________
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