HomeMy WebLinkAboutCLE201500177 Application 2015-09-02Application for Zonis Clearance
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SASE REVIEW ALL 3 SHEETS Check # Date:
Receipt# Staff: %lull _
Tax Map and Parcel: .•.
L+xlsHngZon6rt _T7�hi > .ercp`c 1
Parcel Owmr: 1-0 4 . F 7
ParcelAddrm: City _dMeg-LiState {fl Zip!
(include suite or floor)
PRIMARY CONTACT j
Who should we coNwrite concerning ibb prejuO ZION - U r+L. 0
Address,. 255 k A__ City- State � Zlp _ 9
Office Pheae:Un. E-mail to o rAradt 6
I Cheek any that avoly. - Chanes oimrnershitr - Cbanee of nae ` Change of name X Nese business I
Buslean NaxwTypw
Previous BttsinesR on this
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Desadbe the proposed business lnduding wr amber of employees, number of shifts, available parking wpac esu number of
vddeles, and any additional lnforatation that you can provide:
O9i:is Cie w4c will only be valid on dm prucel for % cb it is appmvmi 7tyou chwi , hums* or moot tte use to is new 10 a aewZorrlag
Cie vwm vn'8 be regsbei
i horaby oerdty the ew 'a Tko
e apace b4kotedos ibis appl adios. lWw certifytmi the Wo madon provided
b e Df9w I ndhiew of appmat =derstand them, and SMI vMI ahWe by them
Signature Printed ):?CLU /1�l 1 [) fh' i1 r .
APPROVAL EVORMATION
AWMed as pgwed C ] Approved with conditions [ ] Denied
) Backflow prevention device and/or current tact dem needed fi v oris site. Contact ACSA, 977-4511 xI k 7.
[ ] No physical site inspection has been done for this alasrnnce. Therdom, it is not n dehmnination of oomplimme with the existing
site plan. .
[ ]'Phis site complies with the she plan as ofthis date.
Notes.
HuIldiag 016ciai
Zoning OlSCial
Other Officisle-
s
r'
401 McIntire Road Ckerlothavllls; VA 22982 Voice
Date
911
Date^
Date
Munity Development
34) 796.5832 Bare (434)977x4126
Revised VIM I Page 2of3
intake to complete the following:
Y1013,111orPWwning?
b Ifao, give applicant a eJertifled
Beganeer% Report (tom peel.
PIN
them be food preparation?
If so, give applicant a Health Itpartraent fofm.
Zoning nzview em not begin uudl are neve approval fiom Health
Dept. FAX 11A7%
CWk the one that oppliaa
Is parad on private well oru
ifprivoteWell, pfovideHea form.
Taring review eon not begin natal we secoive approval from Health
Dept, FAX DAT$
Circle tho one that applia
Is paracl on c
YIN
Will you be pu ft up a newsap ofany kind? Ifso, obtain proper
Sip permak
Permit p
YIN
Will there be &Wnew oonamcdon or maovadow?
If so, obtain the proper Pazoit.
Permit 0
Zonim, to complete the follovvinc.
to complete the following:
Squaft fOatage ofUset _ 1.5:6,g
' l .
rettlitled as: �
Under Section
SupplemMM7 "guidon Wdon:
Parking formula: r}/
r.�
Staqu
y I N
Items to be, verified in the field;
Inspector: Date:
Notes:
Violations;
Praffers:
Y/(!
6IN
]f at), LizL
s%Lbt
ariamx:
's:
/N
/N
If su, Last
If so, Last:
Clmrances:
SDP's
Revised 7/1/1011 Page of
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