Rev. 10/15
TOWN OF MIDDLEBURG
10 West Marshall Street, PO Box 187
Middleburg, Virginia 20118-0187
540-687-5152 FAX 540-687-3804
APPLICATION
BOARD OF ZONING APPEALS
Type Application: Variance Appeal of Determination Zoning Map Interpretation
Applicant Name: Phone #:
Mailing Address: email:
Affected Property Address: Parcel #:
Subdivision Name: Lot #: Zoning District:
Property Owner Name: Phone #:
Mailing Address: email:
FOR VARIANCES:
Variance requested:
Zoning Ordinance section(s) involved:
Alleged special conditions:
Alleged hardship:
Date of Decision:
FOR ADMINISTRATIVE APPEALS / INTERPRETATIONS:
Appealing Decision by:
Zoning Ordinance section(s) involved:
Nature of alleged error:
ADDITIONAL MATERIALS TO INCLUDE:
Consider including a detailed written description/justification of the request, along with any exhibits to
support the request, such as plats, plans, photographs, etc.
For any such additional materials provided, pleased include twelve (12) copies of each.
(cont. on next page)
Application # BZA
Rev. 10/15
Acknowledgement of Responsibility
I acknowledge responsibilty for all applicable fees per the Town’s adopted fee schedule, which may
include a base fee due at the time of application and additional fees to be billed later, regardless of the outcome
of the request or appeal.
Applicant Signature: Printed Name:
OFFICE USE ONLY
Date Filed: Base Fee: ________ Date Paid: _____________ Application #: BZA
Hearing Date: __________________ Cont. Dates, (if applicable): __________________ __________________
BZA Action: Approval Denied
Conditions:_______________________________________________________________________ __________
__________________________________________________________________________________________
Date of Action:__________________ Recorded by: ________________________________________________
Zoning Administrator
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