HomeMy WebLinkAboutCLE201200085 Legacy Document 2014-05-16. ............... .. . ...... . .
Application fo Zoning Clearance
CLE # 12
-"C)Fr- ONLY
PLEASE REAIE'A ALL 38HEETS
Cheelc#
4
-Receipt
VATICEL [INFORMATION
Tax Map and Parcel, Existing zoning
Parcel Owner:--
Parcel Address: CRY State Zip
(include suite ov floor)
PRIMARY CONT ACT
Who simfid we colt/ rite c muceraing iti tis proJect?
Addms.s:1- city, State
LJ
Office Phone, FAX #C 7 �-065
ANYUCANT WFORMATION
Cheek miy that apply: _ Chart -ge arom-mer"51011 Change of aame New business
.. .. ......... .......... ........ . ...... . . . .
Husivess Nan ry pe: Hi, Iix
Previous Business on rlds site
.Deserlie the propoied buginess number of empla V rkingspaces,num0er,of
vthi&-s, and any additional inka,matiou that Y�u can provide: v-
Clearance will be requir,-A
'Ibereby certify iliac I own or have the owners permission tozusethespac6intiicatedout this application. T also cerUfy that the informa6mi provided
is true and arcor-at un the b -,m oymv knowtedgeJ have read. (lie couditioris ot'approvajIl, and, I underm.and fhenj,-miet dint1m,41I.-abide by them.
TI/
Printed' �A-
SiLinatuce z lui�
APPROVAL INFORNIN-TION
jApprove'd as proposed I 1:Appraved with conditions Denied
CotttactAC3A.,977-45H,xlI7.
] No physical site inspection Ims been done for this clearan".
site plan.
[ ] 7-hissite complies with the site plan as of this date.
Notes:
Date
zollitta Official 1
Offier Officiat Date
C.ouniy of Ati)eiiiiric.Dtpartti(teTtt, (if 'Ct)ni€titinitv Di!N'Llopineut
4011 iMefotire Read CltarlotOsville, 1VA. 22902 Voi.ce. (4 4) 296-:5931 972-4116
Revised "TI/
see
Intake to complete the following: I Reviewer to complete the following:
Y / N Square footage of Use:
Is use in LI, HT or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet. Y / N
Permitted as:
Y/N
Will there be food preparation? Under Section:
If so, give applicant a Health Department form.
Zoning review can not begin until we receive approval from Health Supplementary regulations section:
Dept. FAX DATE
Circle the one that applies Parking tormula:
Is parcel on private well or public water?
If private well, provide Health Department form.
Zoning review can not begin until we receive approval from Health Required spaces:
Dept. FAX DATE
Y/N
Circle the one that applies Items to be verified in the field:
Is parcel on septic or public sewer?
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
# Inspector : Date:
Permit
Y / N Notes:
Will there be any new construction or renovations?
If so, obtain the proper Permit. _
Permit #
Violations: v
Y/N
If so, List:
Proffers:
Y/N
If so, List:
Variance:
Y/N
If so, List:
SP's:
Y/N
If so, List:
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3