county of fairfax, virginia i§i+§c•lli~'·*i§+
TRANSCRIPT
DATE:
TO:
FROM:
SUBJECT:
REF.:
County of Fairfax, Virginia
May 25, 20 16
i§i+§C•lli~'·*i§+ Office of the County Attorney
Suite 549, 12000 Government Center Parkway Fairfax , Virginia 22035-0064
Phone: (703) 324-242 1; Fax: (703 ) 324-2665 www.fairfaxcounty.gov
Deborah Pemberton, Senior Applications Acceptance Planner Applications Acceptance Section
RECEIVED Department of Planning & Zoning Zoning Evaluation Division
Department of Planning and~
Sepideh Aflaki-K.hosrowshan1 , Paralegal Office of the County Attorney
MAY 2 7 2016 Zoning Evaluation Division
BZA Affidavit Temporary Application No SP 20 16-0144
135030
Attached is a copy of an application and an original affidavit that has been approved by the Office of the County Attorney fo r the fo llowing case:
ame of Applicant Affidavit Date of Oath
Inderbir Singh 5/18/16
Attachment
\\s 17PROLA WPGCO I \Documents\! 35030\SAK\Affidavi ts\7972 11 .doc
.I
OWNER CONSENT I AGENT AUTHORIZATION STATEMENT
To Whom It May Concern:
:x:-"" .D ;;.~,g I /Z- SI MC. H 4 ._D f\ (... \>-' I >-l 6) .6~ 'Z)M f} L
I/We, C...~ \.l Mo\+-G-A.. 4 Gu6t.ti1A-t- \-<Au~ , the undersigned applicant and/or title
owner(s) of the property identified below, do hereby authorize :;r:: tV..D§i".~ 1 f3-- __S?, ~ c. 1-l ,
to act as agent(s) in the furtherance of an application for a special permit on my/our property
locatedat: \\'1?t:>8 W~}T1.>-1C.To1'1 ~]";
Tax Map No. c:::> 61-\ o\.,\ ~o-1 '3..
Thank you in advance for your cooperation.
APPLICANT/TITLE OWNER
By: =~::_;~
. fn
The f~egoing instrument was acknowledged before me this / Z_ - day of by i 'Jw,nder .~, ~,-, ct} .
H(.{U , 201£, I
(Signor)
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Notary Public (Signature) -Notary Registration No. '757890 Z My Commission Expires: 40;, ;-~cc
135 :::2.C>l6 ; 7
ALL TITLE OWNERS MUST SIGN IN PRESENCE OF NOTARY. IF THERE rs MORE THAN ONE OWNER, SIGNATURES MAY CONTINUE ON NEXT PAGE.
44
1
Owner Consent I Agent Authorization Statement Page 2 of2
CO-TITLE OWNER
Date: _s--!--/ _J 1-+-( /_6 _ By: _ · .,____~-~----,,,~-=-~----" --
The fqrei;ojng instrume,"t was acknowledged before me this ) :f1tctay of~ 20 jiL_, by 1--aJ_-h t/oAc, . UH ___ /
(Signor)
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45
Owner Consent I Agent Authorization Statement Page 2 of2
CO-TITLE OWNER
COMMONWEALTH/STATE OF: ~ · c'> r G CITY/COUNTY OF: ~· .d-<~~...,._._,_;!_,__,-f-'--_,_,=-"'~~-0-WI-T-: ----
The forego)Iig ins~ent was acknowledged before me this ) 9' fEaay of /i au , 20 lb , by Uurdro. / t5fil,.r .
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(Signor)
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Notary Public (Signature) NotaryRegistrationNo. 1/51~/ My Commission Expires: /'vfff,.:Zhr p o:<c:Jt6
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45
OWNER CONSENT STATEMENT
To Whom It May Concern:
::CIV~,~~~I ~ S:-1r-lC.'H f i)~ 1..-v.:> I >-I .l::l&.R_ -S"o-M~ L
I, t..-~~ 11 _g 0\ott-~ ~ Cut<c,~L \-<'.'10G<... , the undersigned title owner of the property
identified below, do hereby authorize :CN!Jf..!i2...R 1 R .<: 1 rt c.. 1-1 , to apply for a Special
Permit/Special Permit Amendment on my/our property located at:
\\ CS'o8' V--'ft-..S\'t \>-IC..\ol'J ~\ , 1= fr1~Ffbl. \}A- J)..,,_c::>.3 D
Tax Map No. _o_6~~~1_o_y-+,-o~e:>-:Z~3.~
Thank you in advance for your cooperation.
TITLE OWNER
Date:
COMMONWEALTH/STATE OF: ----'-\/'--'--", J->-+.{---'· ·n~r ..... a..,.., ____ _
hc·h2x. , TO WIT: CITY /COUNTY OF:
The foregoing instrument was acknowledged before me this
20)£_, by fJ/w:nJcr <S·orn c,._f (Signor)
Notary Public (Signature)
''''""''''' ,,,, 'a.cock 111,
~ <)0 •••••••••• * ,, ' ' •• \th •• ~ ~ r,. .·~0~ ··. , Notary Registration No. 75>78;:<.o7
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My Commission Expires: /l£t:t ,.,,jc!,.'\ ?lj d.O/£
46
OWNER CONSENT STATEMENT
To Whom It May Concern:
.:C1Vu•S~~,p..._~1r-lc.~ f .D~1.-V-!>1>-'~&.A.. ~o-Nl~L
I, !.--~~\-'I _g t"'o»-~ ~ Cuf2.c,AL \-<'.AUR. , the undersigned title owner of the property
identified below, do hereby authorize ::CN-bf..1)2.£ 1 f?.,_ • C: 1 ;--1 c. 1"' , to apply for a Special
Permit/Special Permit Amendment on my/our property located at:
l\ C3o'ES V-'fr..Srt1>-lc..\«::. !'J ~'T . f A-1i:.FA":>l. \IA- Jl~o -30
Tax Map No. _0_6---''"'-1-_,l_o_Lj-\1-=cs-"c:>'--""'j_.,__'S...__
Thank you in advance for your cooperation.
Date: AiJ . ~
Iv I c-t,{,,1 If & o /£ u
TITLE OWNER
By: --~-_,,""""'-~~'--o·,-=~-=(_'-'-f;-"'·~=~' __ (signor)
C011MONWEALTH/STATE OF: -·~~·5~,_.,.1~·0~< =a ______ _
CITY/COUNTY OF: J;;;ch...x· , TO WIT:
The foregoing instrument was acknowledged before me this
20-J/i_, by Gurdia._/ .})'~u.r-(Signor) ·
. ,,,,,,,,,,,,, ,,,,, -a.cock 11,,
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Notary' Public (Signature)
Notary Registration No. 757 ~O/ My Commission Expires: /1£-.crrzh·rL30,,i!._0/6
7
46
OWNER CONSENT STATEMENT
To Whom It May Concern:
:::r::"!V.U.S~~I p.._ S:1r--\C.°'4 f j)~ 1.-V--l' I>-°' ,D~R_ _go-NI~ L.
I, /...-&£ \--\ _g (Ylott-Gfl.- ~ c~c,f}L l<~G<... 'the undersigned title owner of the property
identified below, do hereby authorize :r:N.!:::.f-1/2....2 1 R . ~ 1 rt c. 'H , to apply for a Special
Permit/Special Permit Amendment on my/our property located at:
\\C?o8' \.IJfr...S.\"t\>-IC.\o/"J .,g:\, 1=e-1~F6'r.,Z... \)fr Jl~=-30
Tax Map No. _o_6___,~~l_o_L\~,-=e:>~c:>~1~7>~
Thank you in advance for your cooperation.
TITLE OWNER
Date: /Vl jt, u/q f2_o!( By: __ t~t.-~'_k ~.,,..-=--,,----~_-·,.......--, ____ _
(signor) ,/
COMMONWEALTII/S~ATE OF: V::--3 in ( a.
CITY/COUNTY OF: / ; ;;; c(o__x , TO WIT:
The foregoing instrument was acknowledged before me this / pf day of /iv , I 2o_f£__, by_h~bh_'1 _1_S~fln~~h~c1,,,--__ _
(Signor)
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Notary Public (Signature)
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My Commission Expires: /1,/o J/[l~cr 3tJ ;20/b ,)
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AFFIX uor;. R ,r.:;T AMP 1ffi1tt\
46
- _ __J
I 3506'0 COUNTY OF FAIRFAX APPLICATION No:---------Department of Planning and Zoning Zoning Evaluation Division 12055 Government Center Parkway, Suite 801 Fairfax, VA 2203 5 703-324-1290, TTY 711 www.(air(axcounty.gov/ dpzlzoningl applications
(Staff will assign)
RECEIVED Depanment of Pia ning & Zoning
f. ·~y l 9 2016
Zoning Evaluation Division APPLICATION FOR A SPECIAL PERMIT I SPECIAL PERMIT AMENDMENT
(PLEASE TYPE or PRINT IN BLACK INK)
APPLICANT NAME -:r: ,...; -D &-P---2, R ~I .H~ 1-1
BUSINESS NAME (if applicable) (e.g., d/b/a; aka; LLC; trading as, etc.)
APPLICANT MAILING ADDRESS II So~ WfKtrJ 1,_1 c..-ro N ...fT 1= f.rr fl. f-~ v f-t Jl-~3o
PHONE HOME( ) WORK( )
PHONE EMAIL: MOBILE (?-o-3) 96 er - Lf o.). \ :::r= B.$1>-J C.l·I. R.GtlLloll... Q C..v1~1 .... .. eo-
PROPERTY ADDRESS \\808> \..U ~~ 1~ c..\eN ..{\,
F t-'l-1 cP--r A-~ \)A _):Lo -3 D
TAX MAP NO. SIZE (ACRES/SQ FT) PROPERTY 06~\ DL\ 00 _,_ ~ 1 . cJ2 I J,13,~-
INFORMATION ZONING DISTRICT MAGISTERIAL DISTRICT R[ v1c:, - - - - - - )1r:.,uee)R_
PROPOSED ZONING IF CONCURRENT WITH REZONING APPLICATION:
SPECIAL PERMIT ZONING ORDINANCE SECTION
REQUEST PROPOSED USE INFORMATION
NAME
MAILING ADDRESS AGENT/CONTACT
INFORMATION PHONE NUMBER HOME WORK
PHONE NUMBER MOBILE
MAILING Send all correspondence to (check one}: ~ App~cant -or- LJ Agent/Contact
The name(s) and addresses of owner(s) of record shall be provided on the affidavit form attached and made part of this application. The undersigned has the power to authorize and does hereby authorize Fairfax County staff ~entatives on official business to enter the subject property as necessary to process the application.
_L ,N .Ll GRQ...1 ~ ~ IJ-l c.t-1 --TYPE/PRINT NAME OF APPLICANT/AGENT SIGNKI URE OF APPLICANT/A&~NT
DO NOT WRITE IN THIS SP ACE Sf Zol'1- O!lft/
Date Application accepted: Application Fee Paid: $ _______ _
11
Application No.(s): ---------------------------(county-assigned application number(s), to be entered by County Staff)
SPECIAL PERMITN ARIANCE AFFIDAVIT
DATE: (enfrtlt~ J!itvit is notarized)
I, __ -r.. __ r-J_e_G_R_~_- _, _R. __ ~_,_.N_C._\.\ _ _________ , do hereby state that I am an (enter name of applicant or authorized agent)
(check one) applicant [XI [ ] applicant' s authorized agent listed in Par. l(a) below
and that, to the best of my knowledge and belief, the following is true:
l(a). The following constitutes a listing of the names and addresses of all APPLICANTS, TITLE OWNERS, CONTRACT PURCHASERS, and LESSEES of the land described in the application,* and, if any of the foregoing is a TRUSTEE,** each BENEFICIARY of such trust, and all ATTORNEYS and REAL ESTATE BROKERS, and all AGENTS who have acted on behalf of any of the foregoing with respect to the application:
(NOTE: All relationships to the application listed above in BOLD print must be disclosed. Multiple relationships may be listed together, e.g., Attorney/Agent, Contract Purchaser/Lessee, Applicant/Title Owner, etc. For a multiparcel application, list the Tax Map Number(s) of the parcel(s) for each owner(s) in the Relationship column.)
NAME (enter first name, middle initial, and last name)
:C,..; D E P-- 2 I P-. _s", ,_,Cd-I
ADDRESS (enter number, street, city, state, and zip code)
\\ 80(:3 W~HJ~t..-ro!V ~I ·
F tl-l~F-~:>l.. Vi+ ,)~e>3D
\ \ 0'08 \)-l>~'tt"l~C.\o,V ..(\ .
p.~, i\-F 14--,1._ \.) .q ).. '- o .3 =
RELATIONSHIP(S) (enter applicable relationships listed in BOLD above)
(\)opt.; ~i.- ; 11 -f-1,._
~ J r-t (,,.. H tvlolt~ \\Bo~ V.J-A-..S~lrvC.. ~cN .!\ ·
(check if applicable)
\\Bo~ \J...!>~~\+\Nl--\ON ..!\ .
f-{>t-\i;\,.~~~ \Ji'I )- ~C> 2.-c>
[ ] There are more relationships to be listed and Par. l(a) is continued on a "Special Permit/Variance Attachment to Par. l(a)" form.
* In the case of a condominium, the title owner, contract purchaser, or lessee of 10% or more of the units in the condominium. ** List as follows : Name of trustee, Trustee for (name of trust, if applicable), for the benefit of: (state
name of each beneficiary).
FORM SPNC-1 Updated (7/1/06)
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Application No.(s): - -----------------------------(county-assigned application number(s), to be entered by County Staff)
Page Two SPECIAL PERMITNARIANCE AFFIDAVIT
DATE: _s/1s /l£ (enter date affidavit is notarized)
l(b). The following constitutes a listing*** of the SHAREHOLDERS of all corporations disclosed in this affidavit who own 10% or more of any class of stock issued by said corporation, and where such corporation has 10 or less shareholders, a listing of all of the shareholders:
(NOTE: Include SOLE PROPRIETORSHIPS, LIMITED LIABILITY COMPANIES, and REAL ESTATE INVESTMENT TRUSTS herein.)
CORPORATION INFORMATION
NAME & ADDRESS OF CORPORATION: (enter complete name, number, street, city, state, and zip code)
DESCRIPTION OF CORPORATION: (check one statement) [ ] There are I 0 or less shareholders, and all of the shareholders are listed below. [ ] There are more than I 0 shareholders, and all of the shareholders owning I 0% or more of
any class of stock issued by said corporation are listed below. [ ] There are more than 10 shareholders, but no shareholder owns I 0% or more of any class
of stock issued by said corporation, and no shareholders are listed below.
NAMES OF SHAREHOLDERS: (enter first name, middle initial, and last name)
(check if applicable) [ ] There is more corporation information and Par. l(b) is continued on a "Special Permit/Variance Attachment I (b )" form.
***All listings which include partnerships, corporations, or trusts, to include the names of beneficiaries, must be broken down successively until (a) only individual persons are listed or (b) the listing for a corporation having more than IO shareholders has no shareholder owning 10% or more of any class of stock. In the case of an APPLICANT, TITLE OWNER, CONTRACT PURCHASER, or LESSEE* of the land that is a partnership, corporation, or trust, such successive breakdown must include a listing and further breakdown of all of its partners, of its shareholders as required above, and of beneficiaries of any trusts. Such successive breakdown must also include breakdowns of any partnership, corporation, or trust owning 10% or more of the APPLICANT, TITLE OWNER, CONTRACT PURCHASER or LESSEE* of the land. Limited liability companies and real estate investment trusts and their equivalents are treated as corporations, with members being deemed the equivalent of shareholders,- managing members shall also be listed. Use footnote numbers to designate partnerships or corporations, which have further listings on an attachment page, and reference the same footnote numbers on the attachment page.
29
_Application No.(s): --------- ---------------------(county-assigned application number(s), to be entered by County Staff)
Page Three
SPECIAL PERMITN ARIAN CE AFFIDAVIT
DATE: -<( l ~ \ 16 (enter date affidavit is notarized)
l(c). The following constitutes a listing*** of all of the PARTNERS, both GENERAL and LIMITED, in any partnership disclosed in this affidavit:
PARTNERSHIP INFORMATION
PARTNERSHIP NAME & ADDRESS: (enter complete name, number, street, city, state, and zip code)
(check if applicable) [ ] The above-listed partnership has no limited partners.
NAMES AND TITLE OF THE PARTNERS (enter first name, middle initial, last name, and title, e.g. General Partner, Limited Partner, or General and Limited Partner)
(check if applicable) [ ] There is more partnership information and Par. l(c) is continued on a "Special Permit/Variance Attachment to Par. 1 ( c )" form.
***All listings which include partnerships, corporations, or trusts, to include the names of beneficiaries, must be broken down successively until : (a) only individual persons are listed or (b) the listing for a corporation having more than IO shareholders has no shareholder owning 10% or more of any class of stock. In the case of an APPLICANT, TITLE 0 WNER, CONTRACT PURCHASER, or LESSEE* of the land that is a partnership, corporation, or trust, such successive breakdown must include a listing and further breakdown of all of its partners, of its shareholders as required above, and of beneficiaries of any trusts. Such successive breakdown must also include breakdowns of any partnership, corporation, or trust owning 10% or more of the APPLICANT, TITLE OWNER, CONTRACT PURCHASER, or LESSEE* of the land. Limited liability companies and real estate investment trusts and their equivalents are treated as corporations, with members being deemed the equivalent of shareholders,- managing members shall also be listed. Use footnote numbers to designate partnerships or corporations, which have further listings on an attachment page, and reference the same footnote numbers on the attachment page.
30
Application No.(s): - - - -------------------------(county-assigned application number(s), to be entered by County Staff)
Page Four
SPECIAL PERMITN ARIAN CE AFFIDAVIT
DATE: s/ IR ] I 6 (enter date affidavit is notarized)
l(d) . One of the following boxes must be checked:
[ ] In addition to the names listed in Paragraphs l(a), l(b), and l(c) above, the following is a listing of any and all other individuals who own in the aggregate (directly and as a shareholder, partner, and beneficiary of a trust) 10% or more of the APPLICANT, TITLE OWNER, CONTRACT PURCHASER, or LESSEE* of the land:
[)(J Other than the names listed in Paragraphs l(a), l(b), and l(c) above, no individual owns in the aggregate (directly and as a shareholder, partner, and beneficiary of a trust) 10% or more of the APPLICANT, TITLE OWNER, CONTRACT PURCHASER, or LESSEE* of the land.
2. That no member of the Fairfax County Board of Zoning Appeals, Planning Commission, or any member of his or her immediate household owns or has any financial interest in the subject land either individually, by ownership of stock in a corporation owning such land, or through an interest in a partnership owning such land.
EXCEPT AS FOLLOWS: (NOTE: If answer is none, enter "NONE" on the line below.)
(check if applicable) [ ]
1' f\)oJ'1 G ''
There are more interests to be listed and Par. 2 is continued on a "Special Permit/Variance Attachment to Par. 2" form.
31
_Application No.(s): ---------------- ------------(county-assigned application number(s), to be entered by County Staff)
Page Five
SPECIAL PERMITN ARIAN CE AFFIDAVIT
DATE: _s I \ ~ l \ {, (enter date affidavit is notarized)
3. That within the twelve-month period prior to the public hearing of this application, no member of the Fairfax County Board of Zoning Appeals, Planning Commission, or any member of his or her immediate household, either directly or by way of partnership in which any of them is a partner, employee, agent, or attorney, or through a partner of any of them, or through a corporation in which any of them is an officer, director, employee, agent, or attorney or holds l 0% or more of the outstanding bonds or shares of stock of a particular class, has, or has had any business or financial relationship, other than any ordinary depositor or customer relationship with or by a retail establishment, public utility, or bank, including any gift or donation having a value of more than $100, singularly or in the aggregate, with any of those listed in Par. 1 above.
EXCEPT AS FOLLOWS: (NOTE: If answer is none, enter "NONE" on line below.)
(NOTE: Business or financial relationships of the type described in this paragraph that arise after the filing of this application and before each public hearing must be disclosed prior to the public hearings. See Par. 4 below.)
(check if applicable) [ ] There are more disclosures to be listed and Par. 3 is continued on a "Special Permit/Variance Attachment to Par. 3" form.
4. That the information contained in this affidavit is complete, that all partnerships, corporations, and trusts owning 10% or more of the APPLICANT, TITLE OWNER, CONTRACT PURCHASER, or LESSEE* of the land have been listed and broken down, and that prior to each and every public hearing on this matter, I will reexamine this affidavit and provide any changed or supplemental information, including business or financial relationships of the type described in Paragraph 3 above, that arise on or after the date of this application.
WITNESS the following signatur:__=~-=-~~~·~. ;~==·-=====~~~;;_ _________ _ (check one) [1] Applicant [ ] Applicant' s Authorized Agent
(type or print first name, middle initial, last name, and title of signee)
~ v Subscribed and sworn to before me this I g day of fv1 Ay 20 __Jf_, in the State/cemrn. of
\J \(?.,, () I 1\1 I A,- , County/Qit)' of ("'A i <z f A. )'
My commission expires: 03. (3 I I Ct
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