Certificate of Occupancy Application - Richmond

THIS IS AN APPLICATION ONLY. IT IS NOT AUTHORIZATION FOR USE OF PREMISE.
NO USE SHALL START UNTIL A CERTIFICATE IS ISSUED.
OWNER’S INFORMATION
B
JOB/PROPERTY ADDRESS (STREET & NUMBER)
E
PROPERTY OWNER’S ADDRESS/ZIP
D
PROPERTY OWNER’S NAME (PRINT CLEARLY)
C
FLOOR/ROOM NO.
F
PROPERTY OWNER’S DAYTIME TELEPHONE NO.
G
DESCRIBE CURRENT STRUCTURE USE (IN DETAIL) IF CURRENTLY VACANT, INDICATE LAST USE & YEAR IT WAS LAST USED.
H
DESCRIBE PROPOSED STRUCTURE USE (IN DETAIL)
PROPERTY
INFORMATION
1!
SQUARE FOOTAGE TO BE USED
__________ SQUARE FEET
DESIRED OCCUPANT LOAD PER
FLOOR
__________________
1#
ARE FLOOR PLANS ATTACHED?
YES
NO
YES
NO
YES
NO
IS A SITE PLAN ATTACHED?
__________ PARKING SPACES
IF YES, ATTACH LEASE & SITE PLAN
1$
NO. OF ON-SITE PARKING SPACES
__________ PARKING SPACES
1%
ARE PARKING SPACES LEASED
OFF-SITE
J
RESIDENTIAL USES
ONE FAMILY
TWO FAMILY
THREE OR MORE FAMILY
NO. OF UNITS _________________
LODGING HOUSE
NO. OF ROOMS________________
NO. OF PERSONS______________
NURSING HOME
NO. OF BEDS__________________
ADULT CARE RESIDENCE
NO. OF ROOMS________________
NO. OF PERSONS______________
GROUP HOMES
NO. OF PERSONS______________
NO. OF COUNSELORS __________
OTHER (SPECIFY): _______________
_______________________________
_______________________________
RESTAURANT, SIT-DOWN
RESTAURANT, DRIVE-THRU /TAKE-OUT
NIGHT CLUB
RETAIL STORE
GROCERY/CONVENIENCE STORE
FURNITURE STORE
HARDWARE OR APPLIANCE STORE
SHOPPING CENTER
CLINIC (MEDICAL/DENTAL)
BANK
BEAUTY/BARBER SHOP
LAUNDRY /DRY CLEANER/ LAUNDROMAT
REPAIR SHOP
WHAT TYPE ___________________
OFFICE
CHURCH
NO. OF SEATS _________________
DAY NURSERY
NO. OF CHILDREN _____________
NO. OF STAFF _________________
ADULT DAY CARE
SHELTER/SOCIAL SERVICE DELIVERY
NO. OF ROOMS________________
NO. OF PERSONS______________
SCHOOL
SERVICE STATION
MOTOR VEHICLE REPAIR/SALES
MANUFACTURING FACILITY
NO. OF EMPLOYEES ___________
WAREHOUSE/STORAGE FACILITY
NO. OF EMPLOYEES ___________
NO. OF COMPANY VEHICLES ____
OTHER (SPECIFY): _______________
_______________________________
1)
COMMERCIAL/INDUSTRIAL USES
DEPARTMENT OF PLANNING AND DEVELOPMENT REVIEW
BUREAU OF PERMITS AND INSPECTION
ROOM 110 CITY HALL
900 E. BROAD STREET
RICHMOND, VIRGINIA 23219
PHONE (804) 646-4169
FAX (804) 646-1569
DCD02H (Rev. 07/12)
112037-5
PERMIT NO.
H
B
PROJECT NO.
I
OWNERSHIP
CHANGE
TENANT CHANGE
OFFICE
USE ONLY
(CHECK ONE)

PARTIAL C.O.
TEMP C.O. OTHER
CONTACT INFORMATION
1*
APPLICANT’S ADDRESS
1^
APPLICANT’S NAME (PRINT CLEARLY)
1(
APPLICANT’S DAYTIME PHONE NO.
2)
APPLICANT’S FAX NO.
2!
APPLICANT’S EMAIL
2#
CONTACT PERSON (IF DIFFERENT THAN APPLICANT)
2$
CONTACT PERSON DAYTIME PHONE NO.
APPLICANT’S SIGNATURE
1&
BUSINESS AND/OR TRADE NAME
ZIP CODE
2%
CONTACT PERSON ADDRESS
ZIP CODE
OFFICE USE ONLY
ARTS DISTRICT
EXISTING USE GROUP
APPLICATION APPROVED ON DATE
CONDITIONS
APPLICATION DISAPPROVED ON DATE
REASON FOR DENIAL
VIOLATION ON PROPERTY
PROPOSED USE GROUP
VIOLATION NO. CORRESPONDING CO
PERMIT FEE FEE RECEIVED
CHESAPEAKE BAY PROTECTION AREA?
RECEIPT NO.
CHESAPEAKE BAY MANAGEMENT AREA?
CASH CHECK CREDIT CARD
YES
NO
HISTORICAL DISTRICT
YES
NO
YES
NO
YES
NO
YES
NO
2^
DO YOU WANT TO BE CALLED TO
PICK UP PERMIT WHEN ISSUED?
NAME PHONE NO.
YES
NO
DELINQUENT TAXES DUE? AMOUNT OWED $ DATE PAID
YES
NO
CODE ENFORCEMENT ADMINISTRATOR CODE ENFORCEMENT ADMINISTRATOR
CERTIFICATE OF
OCCUPANCY
APPLICATION
TRACK 1 TRACK 2
Page 1/2
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