HomeMy WebLinkAboutCLE201000186 Review Comments Zoning Clearance 2010-09-13ML�
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Applicati ®n for Z®nin Clearance
CLE #
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OFFICE USE ONLY `D
Zoning Clearance = $35
Check # Date:
PLEASE REVIEW ALL 3 SHEETS
Receipt # Staff*�
PARCEL INFORMATION �VV nn n^ J / c -
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Tax Map and Parcel: e51 Existing Zoning ( j
Parcel Owner:r
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Parcel Address:{ ( J?{ �() em /C�C� City U 0 11'a State _ V Zip lyfl?
(include suite or floor)
PRIMARY CONTACT //��
XIV
Who should we call /write concerning this project? M WA/
Address: 2,ff 61ZI Y !/11/Ue City (��/'� %� State Zip zZ,W1
Office Phone: L_J Cell #_4f1.j' Fax # E -mail
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name /Type:
Previous Business on this site
Describe the proposed business including use, number of employees, number of shifts, available parking spaces, number of
vehicles, and any additional information that you can provide:
*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 new Zoning
Clearance will be required.
I hereby certify that I own or have the owner's pennission to use the space indicated on this application. I also certify that the information provided
is true and accurate to the best f my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature Printed Z�/�' ' •°t%
APPROVAL INFORMATION
V] Approved as proposed [ ] Approved with conditions [ ] Denied
[ ] Backflow 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 `q
Zoning Official Date
Other Official Date
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
Revised 04/28/08, 10/13/09 Page 2 of 3
Intake to complete the following:
Y/N
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y /
Will t sere be food preparation?
If so, give applicant a Health Department 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 or 6�ent er?
If private well, provide Hea form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Reviewer to complete the following:
Square footage of Use: 1�
OIN
Permitted as:
Under Section:
Parking formula:
Required spaces:
Y /&l
Circle the one that applies Items to be verified in the field:
Is parcel on septic or pi6lic sewer?
Y /
Willu, be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit # Inspector : Date:
Y /
W12
il e be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
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Notes:
Viola ti
Y/p
If so, ist:
Proffer :
Y/
If so, -List:
Variance:
Y /: IMF,
If so, )�- fst:
SP's:
Y /
If so, List:
Clearances:
&A
SDP's
- - Revised 04/28/08; 10/13/09 -Page 3 of 3--- - - -
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