HomeMy WebLinkAboutHS202100031 Application 2022-08-11Homestay
Zoning Clearance Application
Submit this completed application wlththe following nnlliieortothe address above:
fAlMmarM �y
42 CommunityDevelopmem
=r 401 McIntire Rd., North Wing
Charlottesville, VA 22902
Phone 434.296.58321 Fax 434.972.4126
Application fee: $158
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 spottguest 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 US. passport, others as approved by the Zoning Administrator)
L Homestay Information
ResidenhaUyzonedandr rdaeopatmisof7esthati5aawnwhow2guestbedtnona6y-rot Use of aaesaorysbuciteec(ffbu#tb*mAtl W7, 202i)is
oypanittedby-riSkon nvdmwpwcdsof5+amm MThdehasetertbikoM'pemitEcdmnadaeaPaaegaFS+aaes
ADDRESS2-3
`I
CITY. STATE. ZIP. -.
C
TAX MAP PARCEL (IF KNOWN}
�(��
ZONING (IF KNOWN}
ADVERTISED NAME OF HOMESTAY BFAPPUCABLEF.
ACREAGE OF PARCEL:
NO. OF GUEST BEDROOMS:
2—
1 USING ACCESSORY STRUCTURES?
[YES ❑NO
WHOLE HOUSE RENTALS
❑YES �*kO
2 Property Owner/Operator Information
'r7.2�IAi NAME
• rr•
3. Responsible Agent Information
The responsible ggentmust beatmtiabk w ittel30 miksof thehomestaydoff lintesduringa hontesbryuse, and mustrespondardatlemptingood faith to
resolveatycofnpkw tsmdm60mkaffiaofbd*contxted.
NAME:
HOME ADDRESS
CITY. STATE, ZIP:
PHONE NUMBER: EMAIL:
4. Signature
I hereby apply for approval to conduct the homestay identified alcove, 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 the homestay as a resident manager. I also certify that 1 have read the
restrictions on homestays, that 1 understilil d them, and vm abi e
SIGNATURE
Fee Amt $158 D.W PPad: (.0,42-7bioal-
Receipt#: t23(o'i,5
Ck#: c�1l'-A /
Received by: C!U l" 12
HSft QOMr C)2 .
DATE:
FOR OFFICE USE ONLY
Safety inspection date ❑ Pass ❑ Fail 2nd inspection date: ❑ Pass ❑ Fail
VDH Food Service (If necessary) ❑ Floorplan - ❑ Parking ❑ ID
Notes Reviewd By.
Date:
Approved Denied
Tau 4uilgUea@o we;piquwngne :ol
AV SG61e LZOZ'Zl ounp :a1e4
loafgng
(7i woo'usw@)ZS[&q uetig :wojj
a
00
00
M
N
A
O
o
J
L.L
z
N
m
L.L
2
C
i
7
7
Q
LO
00
cn
N
2
a