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PHomestay
, Zoning Clearance Application
Albemarle County
Community Development
r 401 McIntire Rd., North Wing
� N
Charlottesville, VA 22902
hrxa>�" Phone 434.296.58321 Fax 434.972.4126
Application fee: $173.76
Submit this completed application with the following online or to the address above: Applicatim $119- Techn.1m Ss rch.,ge $4.76+1 spK ion$so
1. Floor plan/property sketch with labeled structures used for the homestay, guest bedrooms, owner's bedroom, outdoor lighting
and signage for the homestay, labeled setbacks, and parking (minimum 2 + 1 spot/guest bedroom).
2. Copies of two forms of verification of residency (one government issued with photo ID +one listing the address - acceptable forms
include driver's license, voter registration card, U.S. passport, others as approved by the Zoning Administrator)
1. Homestay Information
Residentially zoned and rural area parcels of less than 5 acres may have 2uuest bedrooms by -right Use of accessory structures (if built before August 7, 2019) is
only permitted by -right on rural area parcels of 5+ aaes. Whole house rental is only permitted an rural area parcels of 5+ acres.
ADDRESS:
i, $
Lo4a
CITY, STATE, ZIP:
J
V
TAX MAP PARCEL (IF KNOWNY
— 4
ZONING (IF KNOWN):
ADVERTISED NAME OF HOMESTAY (IF APPLICABLE):
ACREAGE OF PARCEL:
8
NO. OF GUEST BEDROOMS:
2
USING ACCESSORY STRUCTURES?
I ❑ YES ❑ NO
WHOLE HOUSE RENTAL?
I )jID'ES
❑ NO
2. Property Owner/Operator Information
NAME:
HOME ADDRESS:
CITY, STATE, ZIP.
PHONE NUMBER:
EMAIL:
WE
3. Responsible Agent Information J1WZate'�!)1 n�
The responsible agent must be available within 30 miles of the homestay at ail times during o homestay use, and must respond and attempt ingood faith to
resolve any complaints within 60 minutes of being contacted.
NAME: py NJ N G EfV in I r--) 11,
HOMEADDRESS: 2-1 , ,N V 1
CITY, STATE, ZIP: �t /' VA !�
PHONE NUMBER: r) i EMAIL:
4.Signature
I hereby apply for approval to conduct the homestay identified above, and certify that this address is my legal residence, and that I own
the property or that I have recieved a special exception to operate th homestay as a resident manager. I also certify that I have read the
restrictions on homestays, that I understand them, and that 1 will a . e by them. /�
SIGNATURE: DATE: 4 (}J 'O ?j Z
Fee Amt $169 + 4% Date Paid:
Received by:
HS#
FOR OFFICE USE ONLY
Safety inspection date: ❑ Pass ❑ Fail 2nd inspection date:
VDH Food Service (if necessary): ❑ Floorplan ❑ Parking
Reviewd By:
Date:
❑Pass ❑Fail
❑ ID
❑ Approved 0 Denied
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