HomeMy WebLinkAboutCLE200800191 Legacy Document 2013-03-18Application for Z o 'n Clearance
CLE # � 00 ,,,4/ I
PARCEL INFORMA
Tax Map and Parcel:
Parcel Owner
Existing Zoning
Parcel Address:
kinciuue suue or uuur)
Zip
-2_Sp'.3c
PRIMARY CONTACT 22
Who should we call /write concern! ing this prpoject//?����
Address :.� G 5;_� City G- f-:-r State Nf& zil,22919 �
Office Phone: !t ell # d2 2 . G W Fax # -7— E -mail
i�Cf Nl3l1 e �
APPLICANT INFORMA'
Business Name /Type:
frevimm-Business on this
Describe the proposed business including use, number of employees, numl
vehicles, and any additional information that you can provide: Abo -
er of
*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 pemmission to use the space indicated on this application. I also certify that the information provided
is true and accurate to the best of my knowledge. I have read the conditions of approval, and I understand them, alndthat IIwwill abide by them.
Signature / W Printed V� �s�1
APPROVAL INFORMATION
1 1 tipproveu as,proposeu LVJ r�ppr
] Backflow prevention device and /or current test data.n
] No physical site inspection has been done for this clet
site plan.
] Thi�,¢ite complies with the spi plap as of this date
- ,1
4
Notes: (Ilia 1_j IM Gt%91�� -H1k x v�v
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wit
Intake to complete the following:
Y /
Is u LI, HI or PDIP zoning?
Engineer's Report (CER) packet.
If so, give applicant a Certified
/N
ill there be food preparation?
If so, give applicant a Health Department form.
Zoning review can not begin until we receive approval m Health
Dept. FAX DATE s U't•S 6
Circle the one th
Is parcel pri ate we l r public water?
If private e '1, ealth Department form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applies
Is parcel 09y7 a or public sewer?
1.
Y/N
Will you be putting up a new sign of any kind?
Sign permit.
Permit
If so, obtain proper
Y/N
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the following:
Reviewer to complete t�V h /e� following:
Square footage of Use: ' A
miffed as: act
Under Section:
Supplementary regulations ection:
9S
Parking formula:
Required spaces:
Y/N
Items to be verified in the field:
Inspector : Date:
SRI;'
Violations:
Y/N
If so, List:
Proffers:
Y/N
If so, List:
Variance:
Y/N
If so, List:
SP's:
Y/N
If so, Lis .
Clearances:
S 's
Revised 04/28/08 Page 3 of 3