\ I ULl V «mmm FAIRFAX COUNTY, VIRGINIA J L ^r/o, 7 2017 NORTH COUNTY SITE SPECIFIC PLAN AMENDMENT PROCESS :: \/ NOMINATION TO AMEND THE COMPREHENSIVE PI.AN i : y . / / 4 ... w ' fCtl-r. TYPE OR PRINT RESPONSES IN BLACK INK Incomplete forms will not be accepted for review and will be returned to the nominator. Staff reserves the right to correct errors in street address, tax map number, acreage or current Plan designation and may contact the nominator for clarification before acceptance. Be sure to attach required map and original certified mail receipts as proof of property owner notification. THIS BOX FOR STAFF USE ONLY Date Received: Date Accepted: Planning District: Special Area: 1. NOMINATOR/AGENT INFORMATION Name; Elizabeth D. Baker, agent Daytime Phone: 703-528-4700 Address: c/o Walsh, Colucci, Lubeley & Walsh, P.C., 2200 Clarendon Boulevard, Suite 1300 Arlington, VA 22201 Nominator E-mail Address:
[email protected] Signature of Nominator (NOTE: Ttere can be only one nominator per nomination): Signature of dwner(s) if applicable: (NOTE: Attach an additional sheet if necessary. Each owner of a nominated parcel must either sign the nomination or be sent a certified letter): See attached certified letters. Anyone signing on behalf of a business entity, must state the relationship to that organization below or on an attached page: 2. GENERAL INFORMATION Check appropriate | | Dranesville • Hunter Mill \J\ Providence | | Sully supervisor district: Total number of parcels nominated: 6-CIO Total aggregate size of all nominated parcels (in acres and square feet): 86 5 acres sq. 1 Is the nomination a Neighborhood Consolidation Proposal: |L JYes y£jNo (See page 22 of the Guide to the SSPA for more information.