Modified Processing Request Form

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Department of Public Works and Environmental Services, Fairfax County, Virginia
MODIFIED PROCESSING APPLICATION FORM
Request for Application of Modified Processing Procedures
for a Proposed Major Commercial or Industrial Facility
Submit to:
Land Development Services
Modified Processing # _______________
Environmental and Site Review Division
IQ Tracking # _____________________
12055 Government Center Parkway
Suite 535
Date Received: _____________________
Fairfax, Virginia 22035-5503
×
Please include with your application, four (4) copies of the site layout plan (11
14 sheets) showing the
building footprint, location and vicinity map.
PRINCIPAL/PARENT/OWNER/ORGANIZATION INFORMATION
List of the principal(s) that will be involved in this proposed major commercial or industrial
development:
Principal Name:________________________________________ Principal Phone:_______________
Principal Address:___________________________________________________________________
Principal Name:________________________________________ Principal Phone:_______________
Principal Address:___________________________________________________________________
Principal Name:________________________________________ Principal Phone:_______________
Principal Address:___________________________________________________________________
Parent Firm (if applicable):
Parent Firm Name:_____________________________________ Parent Firm Phone:_______________
Parent Firm Address:___________________________________________________________________
Who is the present owner of this site (If the above principal or parent firm is not the current owner,
please attach a copy of documents which indicate that a long-term lease or a contract for the
purchase of the site has been executed):
Owner’s Name: ______________________________________________________________________
Proposed name of organization: _______________________________________________________
PROPERTY INFORMATION
Tax Map: ___________________________________________________________________________
Site Street Address: __________________________________________________________________
Existing zoning of the site: ____________________________________________________________
Rezoning/SE/SP case number: _________________________________________________________
Size of site in acres: __________________________________________________________________
Are the modified processing procedures being requested for:
Construction of a new facility
Expansion of an existing facility
Relocation of an existing facility, which is presently located at _______________________________
Appropriate amount of initial capital investment that has been planned:
Land: ________________________
Construction: ___________________________
Has the project been approved by the Board of Directors?
Yes
No
How will the proposed project be financed?
Personal/Corporation Funds
Commercial Loan
Approved by the Board of Directors
Not yet Approved by the Board of Directors
If you propose to obtain a commercial loan:
Have you applied for a loan?
Yes
No
Have you received approval for financing?
Yes
No
What is the nature of the proposed development?
Transportation
Utilities
Research and Development
Office
Industrial
Retail Trade
Service
Communication
Hotel, motel, or other lodging (# of units ______)
Other (specify): ____________________

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