Rev. 1/18
TOWN OF MIDDLEBURG
10 West Marshall Street, PO Box 187
Middleburg, Virginia 20118-0187
540-687-5152 FAX 540-687-3804
APPLICATION
SPECIAL USE PERMIT
PROPOSED USE: ___________________________________ ZONING ORDINANCE SECTION: __________________________
Attach a detailed description of the proposed use, including any materials required by Ordinance and any addittional
information required to allow the Commission and Council to fully consider the request.
Applicant Name: Phone #:
Mailing Address: email:
Property Address: ____ Parcel #:
Subdivision Name: Lot #: Size of Parcel:
Zoning District: In Historic District?: Yes No # Off-street Parking spaces _________ / _________
required provided
Owner Name: Phone #:
Mailing Address: email:
ACKNOWKLEDGEMENT OF APPLICATION
This application certifies that all affected owners (1) acknowledge their agreement to file this application and (2) authorize
Town representatives and/or its assigns entry to the affected properties without prior notice for the purpose of evaluating the
application. The applicant acknowledges responsibility 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 review fees to be billed later.
Owner Signature: Printed Name:
Applicant Signature: Printed Name:
OFFICE USE ONLY
Date Filed: Base Fee: Date Paid: Application #: SU
Planning Commission Hearing Date: _________ Action Date _________ Recommend: Approval Denial
Recommended Approval Conditions or Reasons for Recommending Denial:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Town Council Hearing Date: _________ Action Date _________ Approved Denied
Conditions of Approval or Reasons for Denial:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
