HomeMy WebLinkAboutCLE201200008 Legacy Document 2012-07-13Application for Zoning Clearance
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CLEVI��
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PLEASE REVIEW ALL 3 SHEETS
OFFICE USE ONLY
Check:# zr 4 Date: 1 'l$ 12
Staff;m J
Receipt # --
PARCEL INFORMATI N
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Tax Map and Parcel
parcel owner:
f/ � ` ✓� State // Zip
Parcel Address: ILI City
(include suite or floor)
PRIMARY CONTACT
Who should )ve call /write concermn this Project? ie�o e, �
Address : � G�Jt' oAJi %�jC�il. hIleStAte /*' Zip
Office Phone 97� Celigl- ��19.999/ Fax# E -wail lyix 1 -14 ze S-q'J
APP ACANT MOMA .ION _
Cheek any that apply!: V Change of mynership Change of use Change of name NeNv business
Business Name/Type: ✓? f7G !/7/�" �1
Pi- evious Business on this site
Describe the proposed business including use,;ltumber of employees, nuniber of shifts, aN,aiialile paritilig splees, ttumber'of
vehicles, and auy 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 th t:I -o or have the owner's perflussion to }t �tl i space indicated on this application. :I also certify that the information' provided
is to the of lulow g have re tf the conditions of approval, and Iundgstand them, and that I will abide by them.
true and ac uzurate
Signature . /�' Printed tcv t�ecx�tS
APPRO'V'AL INFORII7ATION
Appiovcd asproposed [ ] .Approved with conditions [ ] Denied
[ ] Backtlow prevention• device. and /or-current test data needed for this, site. Contact ACSA, 977 - 4511,1;117.
] No physical site inspection has been done for this clearance. Therefore, it is not tl determination of compliance witii'the existing
site plan,
[ ] This site complies with the site plan as of this date..
Notes:
lhtilding Official t---- Date;
Zoning Official" Date '7,��3lZbl
Other Official Date �u
t,;oUll.ry 01. L'l.tUelflin "1C vl +ice, L ........
401 MeltttireRoad Charlottesville, VA 22402 Voice: (434) 296 -5832 F am (434) 972 - 4126'
Revised 7/1/21111 Page 2. of .3
`7 e
Intake to complete the following:
Reviewer to complete the following:
Y /�
Square footage of Use: 11-6'
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
& / N p
Permitted as: C/ of ;S Cba'AY�' Ye
/N
ill there be food preparation ?_ _ _ _
Under Section:_
If so, give applicant a Health Department form.
Zoning review can not begin until we receive ap roval from Health
Supplementary regulations section:
Dept. FAX DATE / /Zn/zd /ti
Circle the o . t at a 'es
Is parcel on iva or public water?
Parking formula:
If private well, provide Health Department form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE //��2 i� zi ���i -2
Required spaces:
b
Y/N
Circle thee-tlrata: plies _
Is parcel n septic public sewer?
Items to be verified in the field:
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit. w��/o/ //a 7�
Permit # �2/
>✓ czar
Inspector : Date:
/
Y / N
Notes:
Will there be any new construction or renovations?
If so, obtain the proper Permit. �o S J
Permit #
7nninv to emmnle e. the fnllnwin4:
Viola 'ons:
Y / N)
If so, List:
Proff rs:
Y /
If so, List:
Variance:
Y/
If so, List:
fS�,P's:
�/N
If so, List:
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3