HomeMy WebLinkAboutCLE200900049 Legacy Document 2012-08-27Application for Zonin Clearance
CLE # 2W = 4
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Zonin Clearance = $35
OFFICE USE ONLY 0 r � i O q'
Check 287 5- I
# Date:
PLEA REVIEW ALL 3 SHEETS
Receipt # �7�/ S j Staff:
PARCEL INFORMATION 1.12 'n A
Tax Map Parcel: Existing Zoning I vb
and
Parcel Owner: Lo&eo %a4 s �. C -»
1111
Parcel Address:-154 051°I�i 8 -S' ty 1 �,V1 LLp State VA- Zip?' 1 Q �
(include suite or floor)
PRIMARY CONTACT ,
Who should we call/write concerning this project? i
tt L �
Address: �, d , l L{�' City � � 10 rW U (Mate Zip 2-10
Office Phone: ' Cell 62Fax # E -mail , h
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name/Type: W1
Previous Business on this site Xaw
Describe the proposed business including use, number of employees, ber of shifts, available parking spaces, number of
vehicles, and an additional information that you can provide: .. r'
*This Clearance will only be valid on the parcel for which it is approved. If you change, intensify or move the use to a new location, a new Zoning
Clearance will be required.
I hereby certify that I own or have the owner's permission to use the space indicated on this application. I also certify that the information provided
is true and accurate to the best of my know edge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature Printed-
AMP-OVAL INFORMATION
[ Approved as proposed [ ] Approved with conditions [ ] Denied
[ ] Backilow prevention device and/or current test data needed for this site. Contact ACSA, 977 -4511, x119.
[ ] No physical site inspection has been done for this clearance. Therefore, it is not a determination of compliance with the existing
site plan.
[ ] This site complies with the site plan as of this date.
Notes:
Building Official Date
Zoning Official Date
Other Official Date
Page 2 of 3
L
Intake to complete the following:
Y /
Is us n LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y/0
Will there be food preparation?
If so, give applicant a Health Department form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applies
Is parcel on private well o�ublic water?
If private well provide Healt3rD� form.
P P wi
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that ap :es " "' "'
Is parcel on septic " public sewer?
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y
Will 'fliere be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the following:
Reviewer to complete the following:
Vj
Square footage of Use: 0 V G
Permitted as: G
Under Section:
Supplementary regulat r6qs section:
Parking formula:
i Z,)Jbo t�
Required spaces: CN�� `" "' �(�r✓��_
w
YIN
Items to be verified in the field:
Viola ' ns:
Y ION
If s st:
Proffers:
YIN
If so ist:
Vari ce:
Y N
If s ist:
SP's:
YIN
If so, List:
Clearances:
SDP's
Revised 04/28/08 Page 3 of 3