TOWN OF MIDDLEBURG
10 West Marshall Street, PO Box 187
Middleburg, Virginia 20118-0187
540-687-5152 FAX 540-687-3804
ZONING OCCUPANCY PERMIT
Proposed Use: Size (sq. ft.) of occupancy: __________
If applicable: Business Name: _______________________________
Former Use: _________________________________
Other Existing Uses: ___________________________ Size (sq. ft.) of other uses: __________
Site Address: Parcel #:
Subdivision Name: Lot #: Lot Size:
Zoning District: In Historic District?: Yes No # Off-street Parking spaces /
required provided
Applicant Name: Phone #:
Mailing Address: email:
Prop. Owner Name: Phone #:
Mailing Address: email:
I, as owner or authorized agent for the above-referenced parcel, do hereby request a zoning occupancy permit for
the activity described herein and as shown on the attached plat, plan and/or specifications. I agree to comply with the
conditions of this permit and all other applicable requirements of Middleburg development regulations:
Owner signature: Applicant Signature: ________________________
Printed Name: Printed Name: _____
OFFICE USE ONLY
Date Filed: ___ Fee amount: _____ Date Paid: __________ Permit #: ZO
Other Required Approvals or Fees Due: ___________________________________________________
Conditions of Approval: ______
______
Approved: ___________ Date: ___________
Zoning Administrator
THIS PERMIT EXPIRES ONE YEAR FROM THE APPROVAL DATE
IF THE AUTHORIZED USE OR ACTIVITY IS NOT COMMENCED AS APPROVED.
Application # ZO ___________
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