HomeMy WebLinkAboutCLE201200146 Legacy Document 2012-07-13Application for
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JZo�Clearance,,.,.`
CLI # //I / — /�
PLEASE RRVIRW ALL 3 SHE, ETS
OFFICE USE ONLY
Check # l z Date: ! �
Receipt # U 7 Staff:
PARCEL INFORMATION {{}} y { n
01 0 " DO 'DU ' �7 JJ P
Tax Map and Parcel: S') / 4 Existing Zoning
Parcel Owner: PG\,lti) r-S C?xrA` -" LLr✓
Parcel Address: Jn4 l?(eh" City C(�arlesifD- 8,hift2State� Zip 2-41.1
(include suit or floor)
PRIMARY CONTACT
Who should we call /write concerning this project?
Addtos:IWD %sade —' 4 City CliadafQSU4 /�AState j/iq zip ZL76%
Office Phone: L_) Cell # /7 21' W4ax # E -mail
APPLICANT INFORMATION
Check any that apply: _ Change of ownership _ Change of use Change of name New business
Business Nome/Type: /Ca fiu+a Sf sb i ia. b,_br yt 4a.k -a
1
Previous Business on this site
Describe the proposed business including use, number of employees, number orshifts, available parking spaces, number of
vehicles, and any additional Information that you can provide: �o —/0
-This Clearance will only be valid on the parcel for which it is approved. Ifyou 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 permission to use the space indicated on this application. I also certify that the Information provided
is true and accurate to the best of my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature W Printed
APPROVAL INFORMATION
( ) 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 plait.
[ ] This site complies with the site plan as of this date.
Notes:
Building Official Date Z li !
Zoning Official f Date 'i��/�2d /y
- f_"fF.� Date
Other Official
County or Albemarle Department of uommumty Devempment
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
Revised 7/112011 Page 2 of 3
Intake to complete the following:
Y / ljJ /�
Is u n LI, HI or PDIP zoning? Ifso, give applicant a Certified
Engineer's Report (CER) packet.
there be food preparation?
Reviewer, to complete the following:
Square footage of Use: 1f 00
0/ N
Permitted as: j O (�469,Ji
Under Section:
Ifso, give applicant a Health Department form.
ffers:
(YO/ N
Ifso, List:
Zoning review can not begin until we receive approval from Health
Supplementary regulations section:
Dept. FAX DATE
Parking formula:
J
Circle the one that applies
Is parcel on private well public water?
If private well, provide H urrt-f6rm.
Zoning review can not begin until we receive approval from Health
T
Required spaces: L
Dept. FAX DATE
SP's:
/N
Ifso, List:
2 aa2 - -S?
Y/
Items to be verified in the field:
Circle the one that appli
Is parcel on septic, or blic sewer•?
Y/N
Will you be putting up anew sign of any kind? Ifso, obtain proper
Inspector: Date:
PN
Sign permit.
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Notes:
there be any new construction or renovations?
Ifso, obtai the �r pep�err P it ,
{�eGr /'my
Permit #PkiI + /. 1' /7(V5J
'
7nninv to cmmnlete the fnllnwinac
Violations:
�/N
so, List: tin
ffers:
(YO/ N
Ifso, List:
Variance:
Y(
Ifso, ist:
SP's:
/N
Ifso, List:
2 aa2 - -S?
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3
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