HomeMy WebLinkAboutCLE201100145 Review Comments Zoning Clearance 2011-08-29n V - 1.
Application for 7fSin Clearance,
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CLE # ao i j
O r DICE USE L,X
# Date: D
PLEASE REVIEW ALL 3 SHEETS
Check
Receipt # Staff; tort,
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PARCEL INFORMATION r RA
72, �arte 3�._ Existing Zoning
Tax Map andParcel:
IA-ipe
t I
Parcel Owner: A l i %� &—,6=1 e5 A i be ma r1!.-
Parcel Address: tie I Adler It w City( k-rlu Z AtAk State \)A Zips %CJ,3
(include suite or floor)
PRIMARY CONTACT'
�N l�t°o1C
Who should we call /writte concerning this project?
Address: Wgtl 6r<ol rd✓15 � 1 City LVOC4 State V77 Zip . ' 3
Office Pllon0: 11AI) 2, 7i-:M63 Cell # IWYa-0'-/27F Fax # E -mail
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use C hange of name New business
\ - _
Bus inessName/Type: �efi►Lr? d'r.��T- &tp 2,Ve f,O� F-J seNVtCQ
Previous Business on this site i.s kkle S'ery : c e. Co r,:� l a coo r
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: r2ad Sff Tr- v rd,, -Ara Ad -T-6r
r 5�1.d Coh -n•ur:
*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 or av tl owner`s p rmission to use the space indicated on this application, I also certify that the information provided
is true and accurate t e be t m lrno d , I have read the conditions of approval, and I understand therm, and that I will abide by them,
Signature Printed �J�'t'� �i J�v�lG
APPROVAL INFORMATION
Approved as proposed [ ) Approved with conditions [ ] Denied
Backfldw 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:
�-
ficial �..Q.,� Date
Building Of
Zoning Official Date.
` Date D 11a l 1
Other Official : f 4 204;; .'b„cNan.cA —
county orawemar:eLeparrmenc yr %.eauuMAa4Ly a,uvuauyu.uuL
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
Revised 1/112011 Page 2of3
Intake to complete the following:
Reviewer to complete the following:
Y / N
Square footage of Use:
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet,
Y / N
Qill N
Permitted as:
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 on
Parking formula:
Is parcel o rlvate w or public water?
If private well, provide Foalth Departmcnt form.
Zoning review can not begin until we receive approval from Health
Required spaces:
Dept. FAX DATE
Y/N
Circle the o3q..tbg applies
Items to be verified in the field: .
Is parcel t septic r public sewer?
Y /�l
Will you be putting up a new sign of any kind? If so, obtain proper
Inspector : Date:
Sign permit.
Permit #
Y / N
Notes:
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Znnina to emmnlete the fnllnwina-
Violations:
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 1/1/2011 Page 3 of 3