Commercial Building Clearance Application Form - City Of Suffolk Department Of Community Development
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1CITY OF SUFFOLK DEPARTMENT OF COMMUNITY DEVELOPMENT
COMMERCIAL BUILDING CLEARANCE APPLICATION
$ 100.00 FEE WITH COPY OF SIGNED NOTARIZED LEASE
Commissioner of the Revenue
Zoning Administrator
Building Official
Fire Department/Marshall
Planning Department
(757) 514-4260
(757) 514-4150
(757) 514-4156
(757) 514-7538
(757) 514-4060
PLEASE READ DECLARATION AT THE BOTTOM OF THIS APPLICATION FORM BEFORE SIGNING APPLICATION
□ EXISTING BUILDING
□ NEW CONSTRUCTION (Check one)
ALL APPLICANTS MUST COMPLETE 1 THROUGH 14 BELOW (PRINT ALL RESPONSES)
1.
Property Owner ___________________________________________________________________________________________
2.
Applicant
___________________________________________________________________________________________
3.
Trade Name:
___________________________________________________________________________________________
4.
Are you on
_______ City Water
_______City Sewer
______Well
______Septic system (check those that apply)
5.
Mailing Address: ____________________________________________________________________________________________
Street No./Name /P.O. Box
Suite/Apt. No.
City
State
Zip Code
6.
Property Location: _______________________________________________________________________________________________________
Street Number/Unit
Street Name
7.
Previous Business Name and use (if any): _____________________________________________________________________________________
Treasurer’s Acct. No. & Assessors Map No. ______________________________________ / ____________________________________________
8.
Treasurer’s Acct. No.
Assessor’s Map No.
.
Local Business Phone: ( ) ____________- ________________ Corporate/Main Office Phone: ( )____________-__________________
9
10. Local Contact Person: ___________________________________ Title: ____________________________ Ext. ____________________
11. Email address: ____________________________________________________________________________________________________
12. Detailed description of ALL proposed business activities: (PLEASE BE SPECIFIC)
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
13. Will the facility be altered in any way? Yes [ ] No [ ] If yes, describe in detail proposed changes (PLEASE BE SPECIFIC )
___________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
14. How many employees do you intend to hire? _________________________________________________________________________
DECLARATION: I declare that the statements herein are true, complete and correct to the best of my knowledge and belief. The completion of this
application and payment of tax for a city business license shall be for the location in which you intend to operate. I ACKNOWLEDGE THAT PURSUANT
TO THE CODE OF VIRGINIA AND THE SUFFOLK CITY CODE THAT ALL REAL ESTATE TAXES THAT ARE PAST DUE FOR THE
LOCATION STATED IN NO. 6 ABOVE MUST BE PAID IN FULL PRIOR TO ANY APPROVALS OR INSPECTIONS REQUIRED FOR THIS
APPLICATION.
Applicant’s Signature: __________________________________________________________
Date:____________________________
OFFICE USE ONLY
PROJECT NUMBER ___________________________________
YES □
NO □ AUTHORIZED SIGNATURE/DATE __________________________________
INSPECTIONS REQUIRED
BUILDING
YES □
NO □ AUTHORIZED SIGNATURE/DATE __________________________________
FIRE MARSHAL
YES □
NO □ AUTHORIZED SIGNATURE/DATE __________________________________
HEALTH DEPT.
ZONING APPROVAL
ZONING CATEGORY ______________ UDO CLASSIFICATION : _________________________________
PERMITTED USE YES □ NO □
USE PERMIT REQUIRED YES □ NO □
SITE PLAN REQUIRED YES □ NO □
COMMENT: _____________________________________________________________________________________________
AUTHORIZED SIGNATURE/DATE _________________________________________________________________________
Revised 3/2/2012
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