(Owner) (Address) (TPIN)
By signing below, I certify the following:
1. I am the owner of record for this property, and/ or I have consent from the owner of record.
2. A copy of the declarations page, a certificate of insurance, or a binder of insurance (if newly
applied for) showing general, personal, or premises liability insurance in the name of the
owner/operator, covering the rental of the property to transient persons, with coverage of not
less than $500,000, shall accompany this affidavit. Such insurance coverage must remain in
place at all times while any part of the property is being offered for short-term rental.
3. As the operator of a short-term rental, I am responsible and liable for all taxes that may be
owed, including transient occupancy tax.
4. I have obtained a business license from the Town.
5. This address is serviced by a Virginia-licensed waste management facilities operator.
6. I shall not permit short-term rentals to exceed 104 nights per calendar year.
7. At all times, no more than ten (10) overnight guests shall occupy any short-term rental unit,
or no more than two (2) per bedroom at any one time, whichever is greater.
8. Accessory buildings and structures shall not be used or occupied as short-term rentals, except
upon the issuance of a Special Use Permit by the Town Council.
9. To protect the citizens of the Town from excessive noise, I certify all short-term rentals shall
comply with Chapter 38 of the Town Code.
10. Nothing in this section shall be construed to supersede or limit contracts or lease agreements
between or among individuals or private entities related to the use of real property, including
recorded declarations and covenants, the provision of condominium instruments of a
condominium created pursuant to the Condominium Act (Va. Code § 55-79.39 et seq.), the
declaration of a common interest community as defined in Va. Code § 55-528, the
cooperative instruments of a cooperative created pursuant to the Virginia Real Estate
Cooperative Act (Va. Code § 55-424 et seq.), or any declaration of a property owners’
association created pursuant to the Property Owners’ Association Act (Va. Code § 55-508 et
11. Any conflict with the terms and conditions noted above or with the standards contained in
Smithfield Zoning Ordinance (SZO) Section 2.Z.1 have been resolved as a result of my
successful acquisition of a special use permit from the Town Council, pursuant to SZO
Section 2.Z.1.k, or otherwise, pursuant to SZO Section 2.Z.2.
I declare under penalty of perjury that the foregoing is true and correct.
DATED this the _______ day of _______________, 20______
(Signature of Affiant)
SWORN to and subscribed before me, this the ______ day of ________________, 20_________
2020-09-01 Application Version
310 Institute Street, PO Box 246, Smithfield, VA 23431
Tel: 1-(757)-365-4200 Fax: 1-(757)-357-9933