HomeMy WebLinkAboutCLE201300071 Legacy Document 2013-05-06Application for ZonMg Clearancef'�
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PLEASE REVIEW ALL 3 SHEETS
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Staff:
PARCEL INFORMATION
Tax Map and Parcel. . 0 7 6 6 9 ^ 04.00 d t d 0- Existing zoning
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Parcel Owner: Fg r~ m 'i u o, , L I- 6-
Parcel Address :_ yid Seth , t.,,b 1,e- ",' J City C��I olk Ville' State VOL
Zip s
(include suite or floor)
PRIMARY CONTACT
104 l^
Who should we cal/write concerning this project; ?,
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Address: 2 t' 6 �Y_pitiSS (ly-Jo'- City grL0Vr�V1 t1L- State V o%
Zip
Of rice Phone: �� 8S -ash l( Cell y'"ZY2- 2zZUax# lE; -mail
APPLICANT INFORMATION
Check any that apply: of ownership Change of use Change of name
New business
Business Name/Type; I" A Q°'1 �.1 t� A
PALO)-
Previous Business on this site Gee-0
Describe the proposed business including use, number of emplo ees, number of shifts, available parking
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spaces, number of
vehicles, and any additiona l o matipu that you a ovide; t'l- �-d+ , Gl a q- l "� . so
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,o. wyT) o}y
2
*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 now Zoning
Clearanco will be required.
I hereby certify that I own owner's permission to use the space indicated on this application. I also certify that the
information provided
I true and accurate to th y knowledge. I have read the conditions of approval, and I understand thorn, and that I will
abide by them.
Signature Printed y r L r �G a-
APPROVAL INFORMATION
Approved as proposed [ j Approved with conditions [ I Denied
[ j Backtiow prevention device and/or current test data needed'for this site. Contact ACSA, 977 -4511, x117.
[ ) 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 ��2d
Other Official Date /I_;
Intake to complete the following:
Y
Is use m LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet..
Y /N _
ill there be food preparation?
If so, give applicant a Health bepartment 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 Hea epartment form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applies
Is parcel on septic public sewer
Reviewer to complete the following:
Square footage of Use.
9-/ N
Permitted as: ✓K
Under Section:
Supplementary regulations section:
Parking formula:
Sv sq, -(- fb �LJ, i) c,
Required spaces: (�
Y/N
Items to be verified in the field:
N
-
1 you be putting up a new sign of any kind? If so, obtain proper
Sign permit,
Permit # Inspector • Date:
Y/N
ill there be any new construction or renovations?
If so, obtaMW-
Notes:
nit.
Permit # -)
Zoning to complete the following:
Violat' ns:
Y/
If so, ist:
Proff rs:
Y/�
If so, ist:
Vari ce:
Y/
If so, List:
SP's:
O/N
If so, List:
Clearances:
SDP's
eJ3- 7?
03- 2?
Revised 7/1/2011 Page 3 of 3
CERTIFICATION THAT NOTICE OF THE
APPLICATION HAS BEEN PROVIDED TO THE LANDOWNER
This form must accompany zoning applications (Home Occupation, Zoning Clearance, Zoning
Administrator Determinations or Appeals, Sign Permits, Building Permits) if the application is not the
owner.
I certify that notice of the application,
[County application name and number]
was provided to Ee � n ; w, L L L the owner of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number 0 yb Q L' —00 -00-01 W y by delivering a copy of the application in the
manner identified below:
Hand delivering a copy of the application to Fero^ I J ►' L• �' b `uc�
[Name of the record owner if the record owner is a
person; if the owner of record is an entity, identify the recipient of the record and the recipient's
title or office for that entity]
on 3 -/6 -13
Date .
Mailing a copy of the application to
[Name of the record owner if the record owner is a person;
if the owner of record is an entity, identify the recipient of the record and the recipient's title or
office for that entity]
on
Date
to the following address:
[address; written notice mailed to the owner at the last known address of the owner as shown on
the current real estate tax assessment books or current real estate tax assessment records satisfies
this requirement].
Signature of Applicant
V"40-'r se L V
Print Applicant Name
3 -16 -0
Date
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