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Cumberland County Department of Planning & Zoning ♦ Box 110 ♦ Cumberland, VA 23040 ♦ [PHONE REDACTED] ♦ Fax – [PHONE REDACTED] COMMONWEALTH OF VIRGINIA COUNTY OF CUMBERLAND Site Development Plan Application Form must be completed in ink, Pencil will not be accepted. (Updated 07/07/10) 1. Property Owner (list multiple owners separately, attach additional sheet if necessary) Name: Address: City: State: ZIP: Phone: Fax: Cellular: E-mail: Note: If the property owner(s) as shown by the tax commissioner’s office is (are) not the applicant, the owner’s (owners’) signed and notarized authorization(s) must accompany this application. 2. Applicant (list if not the same as owner) Name: Address: City: State: ZIP: Phone: Fax: Cellular: E-mail: 3. Surveyor/ Engineer/Architect Firm Name: Individual Name: Address: City: State: ZIP: Phone: Fax: Cellular: E-mail: 4. Property Information Property General Property Internal Use Only FILE RECEIPT ---PAGE BREAK--- Page 2 of 2 Cumberland County Department of Planning & Zoning ♦ Box 110 ♦ Cumberland, VA 23040 ♦ [PHONE REDACTED] ♦ Fax – [PHONE REDACTED] Existing Proposed Tax Parcel(s) Involved (fill in table below, list different parcels separately): Parcel Tax Map Number Parcel Acreage Parcel Zoning 5. Certification *If signatory is not owner of record, the attached “Owner/Agent Agreement” must be signed and notarized. The undersigned herby certifies that all information submitted with this application is complete, true and correct. I understand any errors and/or omissions may lengthen the time to process the request. Print Name of property owner or authorized agent Date Signature of property owner or authorized agent Date Print Name of property owner or authorized agent Date Signature of property owner or authorized agent Date