Rev. 8/15
TOWN OF MIDDLEBURG
10 West Marshall Street, PO Box 187
Middleburg, Virginia 20118-0187
540-687-5152 FAX 540-687-3804
APPLICATION
ZONING MAP AMENDMENT
Type Application: Zoning Map Amendment Proffer Amendment
Applicant Name: Phone #:
Mailing Address: email:
Affected Property Address: Parcel #:
Subdivision Name: Lot #: Size of Parcel:
Owner Name: Phone #:
Mailing Address: email:
Owner Signature: Printed Name:
***See Acknowledgement of Application
Continuation sheet attached (if additional properties involved)
Existing Zoning: _________ Existing Proffers? No Yes If yes, attach copy.
Proposed Zoning: _________ Proposed Proffers? No Yes If yes, attach proposed proffer statement.
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.
Applicant Signature: Printed Name:
OFFICE USE ONLY
Date Filed: Base Fee: Date Paid: Application #: ZMA
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:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Application # ZMA
Rev. 8/15
ZONING MAP AMENDMENT
CONTINUATION SHEET
Additional Properties:
Affected Property Address: Parcel #:
Subdivision Name: Lot #: Size of Parcel:
Owner Name: Phone #:
Mailing Address: email:
Owner Signature: Printed Name:
***See Acknowledgment of Application
Affected Property Address: Parcel #:
Subdivision Name: Lot #: Size of Parcel:
Owner Name: Phone #:
Mailing Address: email:
Owner Signature: Printed Name:
***See Acknowledgment of Application
Affected Property Address: Parcel #:
Subdivision Name: Lot #: Size of Parcel:
Owner Name: Phone #:
Mailing Address: email:
Owner Signature: Printed Name:
***See Acknowledgment of Application
Affected Property Address: Parcel #:
Subdivision Name: Lot #: Size of Parcel:
Owner Name: Phone #:
Mailing Address: email:
Owner Signature: Printed Name:
***See Acknowledgment of Application
Application # ZMA
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