2. Date of Request*
   Date of Request
4. Address of Request*
   Street Address, City, State, Zip Code
6. Property Owner
8. Owner Contact Name*
10. Address of Owner*
    Street Address, City, State, Zip Code
12. Telephone No.*
13. Fax No.
15. Email Address
17. Developer (if applicable)
    Street Address, City, State, Zip Code
18. Engineer (if applicable)
    Street Address, City, State, Zip Code
20. Contact Name & Address*
    Street Address, City, State, Zip Code
22. Telephone No.*
23. Fax No.
25. Email Address
27. Statement*

    1. All information is accurate to the best of my ability. By checking this box, you are agreeing to sign and take responsibility for the work on this permit.
29. Site Acreage
31. Parcel Identification*
    Subdivision Lot & Parcel # and/or Tax Map Designation
34. Proposed Square Footage of Structure(s)
36. Proposed Land Use Activity*
38. Vehicles per Peak Hour (VPH)
39. Traffic Impact Analysis
    (if required)
41. Attachments*

    Check all applicable below:

    1. Preliminary Plans of Subject Property
    2. Preliminary Landscaping Plans
    3. Building Elevation(s)
    4. Required Conditional Review Fee - $500
    5. Traffic Impact Analysis Fee ($500-100VPH or less, $1,000-more than 100VPH)
    6. Revised Submission
43. Preliminary Plans of Subject Property*
45. Preliminary Landscaping Plans*
47. Building Elevation(s)*
49. Traffic Impact Analysis
    (if required)
51. Please email attachments to siteplans@colonialheightsva.gov to include with your submission if error occurs attaching files above.
Leave This Blank:


53. 1. Receive an email copy of this form.
54. Email address

    This field is not part of the form submission.

55. Submit

* indicates a required field