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Attorney Fee Disclosure Affidavit document sample
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COUNTY OF PRINCE WILLIAM
5 County Complex Court, Prince William, Virginia 22192-9201
(703) 792-6830 Metro 631-1703, Ext. 6830 FAX (703) 792-4401
Internet www.pwcgov.org/planning
Application Package
for
Special Use Permits
Contents
Instructions ...................................................................... 2-3
Application for a Special Use Permit ..................................4
Fee Calculation Worksheet..................................................5
Request for Modification or Waiver of Standards...............6
Interest Disclosure Affidavit ...............................................7
Special Power of Attorney Affidavit ...................................8
Adjacent Property Owners List Affidavit............................9
Fee Schedule................................................................ 10-15
December 22, 2004 – Revised July 2010 Page 1 of 15
INSTRUCTIONS
All items contained in this application package must be completed and submitted with the
supplemental items identified in the Reference Manual. Additional information may be
requested during the pre-application conference. Please attach additional pages where
necessary to identify all requested information clearly.
Page 4 – Application for a Special Use Permit (required)
Fill in the case name.
Identify the special use permit request(s).
List all affected parcels by GPIN and indicate the zoning and acreage of each parcel.
Describe the location of the property.
Give names of the property owner(s), authorized agent(s), contract purchaser/lessee, and
engineer. Please check the box next to the contact person to whom correspondence on
the application should be sent.
Sign the application. If the owner(s) of the property does not sign the application, a
power of attorney must be submitted; see page 7.
Page 5 – Fee Calculation Worksheet (required)
Complete form based on the attached fee schedule.
Page 6 – Request for Modification or Waiver of Standards
Complete form if a modification or waiver of standards is proposed as part of the special
use permit request. Only those provisions of the Zoning Ordinance or the Design and
Construction Standards Manual which may be waived by the Board of County
Supervisors may be listed on this form.
Note: Plans containing waivers or modifications involving engineering for street standards or
stormwater management facilities must be filed, including filing fee, with the
Development Services Division of the Planning Office and approved concurrent with the
submission of a special use permit application.
Page 7 – Interest Disclosure Affidavit (required)
This form is required to disclose whether or not any member of the Planning Commission
or Board of County Supervisors has greater than ten percent interest in the company, or
relating to the proposal. Must be signed by the property owner(s).
Special Use Permit Application Instructions
December 22, 2004 – Revised July 2010 Page 2 of 15
Page 8 – Special Power of Attorney Affidavit
This form is required if someone other than the property owner(s) is signing the
application and other documents requiring the property owner(s) signature.
Page 9 – Adjacent Property Owners Affidavit (required)
The adjacent property owners list (which may be requested with the pre-submission
package) must be certified by the property owner(s) as being accurate and fulfilling the
requirements of Section 32-700.20(5) of the Zoning Ordinance.
Pages 10-15 – Fee Schedule
Special Use Permit Application Instructions
December 22, 2004 – Revised July 2010 Page 3 of 15
Reset Form
APPLICATION FOR A SPECIAL USE PERMIT
TO THE BOARD OF COUNTY SUPERVISORS OF PRINCE WILLIAM COUNTY, VIRGINIA
Case Name ____________________________________________________________________
The undersigned, being all of the owner(s), contract purchasers or the respective duly authorized
agents thereof, do hereby petition for a special use permit to allow the following (state the
purpose of the application):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
G.P.I.N. # Zoning: Acres:
___________________ ___________________ ___________________
___________________ ___________________ ___________________
___________________ ___________________ ___________________
Property Location (Describe the location of the property by distance, in feet or portion of a
mile, and direction from an intersection of two (2) public roads or streets.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
The name(s), mailing address(es), and telephone number(s) of owner(s), authorized agent(s),
contract purchaser/lessee, and engineer(s) as applicable are (attach additional pages if necessary):
Owner of Property Authorized Agent(s)
name:_______________________________ name:_______________________________
mailing _____________________________ mailing: _____________________________
address: _____________________________ address: _____________________________
phone: ______________________________ phone: ______________________________
Contract Purchaser/Lessee Engineer
name:_______________________________ name:_______________________________
mailing _____________________________ mailing _____________________________
address: _____________________________ address: _____________________________
phone: ______________________________ phone: ______________________________
Please check the box next to the contact to which correspondence should be sent.
I have read this application, understand its intent, and freely consent to its filing. Furthermore, I
have the power to authorize and hereby grant permission to Prince William County officials and
other authorized government agents on official business to enter the property as necessary to
process this application.
Signed this ______ day of _________________________________, ______.
____________________________________
Signature of Owner
(If anyone other than owner is signing, power of attorney must be attached.)
Special Use Permit Application Application
December 22, 2004 – Revised July 2010 Page 4 of 15
FEE CALCULATION WORKSHEET
Special Use Permit request for: _________________________ =$_________*
Special Use Permit request for: _________________________ =$_________*
Special Use Permit request for: _________________________ =$_________*
*Take highest fee only: _______________________________ =$__________
Service Authority Review Fee (if located within service area) +$__________
PWC TIA Review Fee $1,035.00 (Effective July 1, 2010) +$__________
TOTAL $__________
Please note that if a VDOT 527 Review is required (determined at TIA scoping session) a
separate fee must be submitted directly to VDOT. Do not submit the VDOT 527 review fee to
Prince William County.
Special Use Permit Application Fee Calculation Worksheet
December 22, 2004 – Revised July 2010 Page 5 of 15
REQUEST FOR MODIFICATION OR WAIVER OF STANDARDS
Whenever any standard imposed by any provision of the Zoning Ordinance or other County
ordinance may be waived or modified by special use permit conditions approved by the Board of
County Supervisors, this form must accompany an application for special use permit for such
waiver or modification, and may constitute the whole of or a part of such application.
Applicant:____________________________________________________________
Case Name:__________________________________________________________
Please indicate the requested modification(s) or waiver(s) below. Attach a written
statement describing the requested modification or waiver, referencing the citation, and
providing justification for the request.
Waiver of specific requirements of the Subdivision Ordinance, Zoning Ordinance, or
DCSM as it relates to a town center special use permit application. See Section 32-280.34
of the Zoning Ordinance.
Modification of development standards:
Building Height
Floor Area Ratio (FAR)
Signs
See Sections 32-300.05, 32-400.03, 32-400.04 or 32-250.23 and 32-250.24 of the Zoning
Ordinance
Modification or waiver of large, freestanding retail use (big box) standards:
Architectural Design, Landscaping, Lighting, Operations, Parking, or Pedestrian Access
See Section 32-400.15 of the Zoning Ordinance.
Note: Plans containing waivers or modifications involving engineering for street standards or
stormwater management facilities must be filed, including filing fee, with the Development
Services Division of the Planning Office concurrent with the submission of a special use permit
application and approved prior to the case being scheduled for public hearing.
Special Use Permit Application Request for Modification or Waiver of Standards
December 22, 2004 – Revised July 2010 Page 6 of 15
INTEREST DISCLOSURE AFFIDAVIT
COMMONWEALTH OF VIRGINIA
COUNTY OF PRINCE WILLIAM
This _________________ day of ____________________________, _____________,
(Day) (Month) (Year)
I, ______________________________________________________________(Owner)
hereby make oath that no member of the Board of County Supervisors of the County of Prince
William, Virginia, nor the Planning Commission of the County of Prince William, Virginia has
interest in such property, either individually, by ownership of stock in a corporation owning such
land, or partnership, or as holder of ten (10) percent or more of the outstanding shares of stock in
or as a director or officer of any corporation owning such land, directly or indirectly, by such
member or members of his immediate household, except as follows:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________________________
Owner
COMMONWEALTH OF VIRGINIA:
County of ________________________________________
Subscribed and sworn to before me this _____ day of ________________, ______ in my county
and state aforesaid, by the aforenamed pincipal.
________________________________
NOTARY PUBLIC
My Commission Expires: ________________________________
Special Use Permit Application Interest Disclosure Affidavit
December 22, 2004 – Revised July 2010 Page 7 of 15
SPECIAL POWER OF ATTORNEY AFFIDAVIT
COMMONWEALTH OF VIRGINIA
COUNTY OF PRINCE WILLIAM
This _________________ day of ____________________________, _____________,
(Day) (Month) (Year)
I, _________________________________________________________, the owner of
_______________________________________ (describe land by parcel identification number
[PIN]) make, constitute, and appoint _____________________________________,
my true and lawful attorney-in-fact, and in my name, place and stead giving unto said
__________________________________________ full power and authority to do and perform
all acts and make all representation necessary, without any limitation whatsoever, to make
application for said special use permit.
The right, powers, and authority of said attorney-in-fact herein granted shall commence and be in
full force and effect on _______________________, __________, and shall remain in full force
and effect thereafter until actual notice, by certified mail, return receipt requested is received by
the Office of Planning of Prince William County stating that the terms of this power have been
revoked or modified.
_____________________________________
Owner
COMMONWEALTH OF VIRGINIA:
County of ________________________________________
Subscribed and sworn to before me this _____ day of ________________, ______ in my
county and state aforesaid, by the aforenamed principal.
________________________________
NOTARY PUBLIC
My Commission Expires: ________________________________
Special Use Permit Application Special Power of Attorney Affidavit
December 22, 2004 – Revised July 2010 Page 8 of 15
ADJACENT PROPERTY OWNERS AFFIDAVIT
COMMONWEALTH OF VIRGINIA
COUNTY OF PRINCE WILLIAM
This _________________ day of ____________________________, _____________,
(Day) (Month) (Year)
I, ____________________________________________________________________
(Owner/Contract Purchaser/Authorized Agent)
hereby make oath that the list of owner or owners, their agent or the occupant, of each parcel
involved, landowners within 200 feet of all portions of the subject property and all property
immediately across the street or road from the subject property (including those parcels which lie
in other localities of the Commonwealth), any homeowners and/or civic associations having
jurisdiction over the property or within 200 feet of the subject property, the chief administrative
officer of all jurisdictions located within one-half mile of all portions of the subject property, and
Quantico Marine Corp Base or Manassas Regional Airport, if portions of the subject property are
located within 3,000 feet of the boundary of these facilities, is a true and accurate list as
submitted with my application.
_____________________________________
Owner/Contract Purchaser/Authorized Agent
(circle one)
COMMONWEALTH OF VIRGINIA:
County of ________________________________________
Subscribed and sworn to before me this _____ day of ________________, ______ in my county
and state aforesaid, by the aforenamed principal.
________________________________
NOTARY PUBLIC
My Commission Expires: ________________________________
Special Use Permit Application Adjacent Property Owners Affidavit
December 22, 2004 – Revised July 2010 Page 9 of 15
SPECIAL USE PERMIT FEE SCHEDULE
Effective July 1, 2010
In the event that a proposed special use is not clearly described in this schedule, the zoning
administrator shall determine the special use “most like” the proposal and assign the fee
accordingly.
Description Use Fee
Category A – Limited to small- • Family day-care home $115.92
scale uses in the Agricultural and
Residential districts. Also lawful
nonconforming uses
Category B – Nonresidential uses • Child care, 6-9 children $231.84
within residential areas, but not • Group residences, recovery homes
necessarily commercial in nature • Home business (except rural home
business)
• Mobile unit use, ancillary to an
existing church
• Private school, ancillary to a
residence
Category C – Agricultural uses • Adult day care, up to 9 persons $463.68
not related to farming or • Breeding exotic birds and animals
permitted agricultural uses; • Commercial riding facility
temporary public facilities; other • Non-commercial kennel
limited uses not necessarily • Mobile home for caretaker, public
commercial in nature uses only
• Petting Farm
• Ranges, outdoors or indoors, as an
ancillary use
• Rural home business, without
outside storage
Special Use Permit Application Fee Schedule
December 22, 2004 – Revised July 2010 Page 10 of 15
Category D – Non-commercial • Adult day care facility, 10 or more $1,159.20
and commercial uses of minimal persons
impact or intensity. • Child care facility, 10 to 40 children
• Homeless shelter
• Locational advertising signs
• Medical care facility, less than 20
beds
• Private school, as a principal use
(not ancillary to residence)
• Rooftop radio towers over 10 ft.
from roof
• Rural home business, with outside
storage
• Sign package, 1-5 signs
Category E – Commercial uses • Child care facility, over 40 children $1,738.80
with intensity that is semi- • Religious institution
compatible with surrounding uses • Farmer’s market
with relatively few design • Flea market
mitigation measures • Kennel, commercial
• Motor vehicle impound yard, as an
ancillary use
• Motor vehicle parts, with service – 3
or less service work bays
• Motor vehicle sales, limited and
recreational - 3 or less service work
bays
• Motor vehicle service – 3 or less
service work bays
• Outdoor storage
• Private camp
• Ranges, outdoors and indoors,
commercial
• Roadside stands – more than 28 days
• Secondary residential use
• Sign package, 6 or more signs
• Lodging house
• Veterinary hospital, with kennel
• Watchman’s dwelling
Special Use Permit Application Fee Schedule
December 22, 2004 – Revised July 2010 Page 11 of 15
Category F – Greater intensity • B-2 uses greater than 30,000 sq. ft. $5,216.40
commercial activities, and of floor area
activities of potentially greater • Car wash, not self-service
offsite impacts (traffic, noise, • Catering, commercial (on or off
lighting, etc.) premises)
• Cemetery
• Civic club
• Commercial parking lot
• Commercial recreation – outdoors or
indoors
• Conversion to condominium
ownership
• Country club
• Drive-in facilities, other
• Garden center
• HCOD uses not otherwise specified
• Hotel or motel
• Janitorial service
• Medical care facility, 20 or more
beds
• Metal fabrication and signage
• Mortuary, funeral, or wedding
chapel
• Motor vehicle parts, with service – 4
or more service work bays
• Motor vehicle sales, limited &
recreational – 4 or more service
work bays
• Motor vehicle service – 4 or more
service work bays
• Motorcycle sales, including repair
• Nursing home
• Outdoor recreational use
• Religious institutions, with related
facilities
• Restaurant, drive-in
• Self-storage center
• Specialty food stores
Telecommunication towers;
Radio, TV, microwave towers $ 5,040.00
Special Use Permit Application Fee Schedule
December 22, 2004 – Revised July 2010 Page 12 of 15
Category G – Agricultural, • Ambulance service maintenance $6,955.20
residential, or commercial uses facility
which require intense site specific • Civic center
analysis for long-term impacts • Company vehicle service facility
upon the surrounding area • Town Center
• Electronic component, assembly
• Hospital
• Manufacturing/processing of other
products, non-hazmat
• Marina
• Mobile home or office sales
• Motor vehicle auction, wholesale
• Motor vehicle impoundment yard, as
principal use
• Motor vehicle repair, 3 or less repair
work bays
• Motor vehicle sales, limited and
recreational (incl. boats), 3 or less
repair work bays
• Musical instruments,
assembly/manuf.
• Private airstrip, individual owner
• Quick service food store
• Racetrack, equestrian
• Railroad passenger station
• Stadium or arena, indoors/outdoors
• Taxi & limousine operation/service
facility
• Travel trailer and camp park
Special Use Permit Application Fee Schedule
December 22, 2004 – Revised July 2010 Page 13 of 15
Category H – Industrial-type • Airport, heliport $8,694.00
uses, which may involve hazmat; • Asphalt/concrete plant
including commercial uses that • Assembly/proc. of other products,
have potential environmental hazmat
hazards and significant traffic • Extraction of mineral resources and
impacts to surrounding area. related operations
• Hazmat storage facility
• Heavy industry
• Manufacturing/processing and
wholesale, hazmat
• Motor vehicle fuel station, retail
• Motor vehicle graveyard
• Motor vehicle repair, 4 or more
repair work bays
• Motor vehicle sales, unlimited (off-
road and heavy equipment, with
repair)
• Racetrack, motorized
• Research and development, hazmat
• Sawmill
• Testing and experimental labs,
hazmat
• Truck stop, with related facilities
• Water transportation facility
Modification of development
standards based upon the
physical amount of increase
requested
Increase in floor area ratio (FAR) FAR proposed minus
FAR by right divided
by FAR by right X
multiplier $1,120.00
Increased height (#) # of feet over the by-
right limit X multiplier
$115.92. This figure
is per building, per
SUP application
Special Use Permit Application Fee Schedule
December 22, 2004 – Revised July 2010 Page 14 of 15
Other Fees
Service Authority Review Fee – $46.58
Required for most special use permit applications
Expansion or reconstruction of grandfathered uses 70% of current fee
Renewal of SUP 58% of the minimum
fee, but not less than
$336.00
Minor modifications of previously approved SUP conditions 23% of minimum fee
PWC TIA Review Fee (effective July 1, 2010) $1,035.00
VDOT 527 Review* Either $500.00 or
$1,000.00 – as
*Please note that if a VDOT 527 Review is required, a separate fee must be determined by VDOT
submitted directly to VDOT. Do not submit the VDOT 527 review fee to at TIA scoping
Prince William County. session.
Refunds
A refund of 25% of the application fee shall be returned to the applicant if the special use permit
application is withdrawn prior to the submission of a newspaper advertisement announcing the
Planning Commission public hearing. Cases withdrawn after the advertisement will not have any
funds reimbursed.
Special Use Permit Application Fee Schedule
December 22, 2004 – Revised July 2010 Page 15 of 15
