HomeMy WebLinkAboutCLE201200168 Legacy Document 2012-08-10I County mm»munougmommLm;-,m"°"""v°
401 Nicintire Rood Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (43
Revised 7/112011 Page 2 of 3
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PLEASE RE VIEW ALL 3 SHEE TS
OFF ICE, S N1 Y
c4r"" Date: 0-r-y6k),11c,
Recelpt#m Staff:
Parcel Owneri
(include suite or floor)
PRIMARY CONTACT
Address: tote zip )410
APPLICANT INFORMATION
Change of norrie -Neiv business
Business Nnme/Type:
Previous Business on this sit
Describe file proposed business including use, number of employee,, number of shifts, available parking spaces, number of
*This Clearance will only be v lid oil t Fle 'parcel for which I I t is approved. If you change, intensity or move the use to a novi location, a new Zoning
Clearance will be required.
u(
I hereby coro, that I orhave the, owner's permission to use the space indicated on this application. I also certifY Illat tile i r
t or liav
is true and no best of ledge, I have read the conditions of approval lid I understand thern, and that I will abide by thern.,
our
ignature
CApproved as piloposed Approved with conditions Denied
Backflow prevention device andlor current test data needed for this site., C(5ntaot ACSA, 977-4511, x1 17.
No physical site inspection has been done for this clearance. Therefore, it is not a defermination of complianco with the existing
site plan,
[ ) This site complies with tile site plan as of this date..
Notes-
;Building Offlicial Date
Date '?
Zoning Official
Date
Other Official N.-
I County mm»munougmommLm;-,m"°"""v°
401 Nicintire Rood Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (43
Revised 7/112011 Page 2 of 3
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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 / rN
Will there 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 Z
Circle the one that applies, "
Is parcel on private well`or ublic Ovate ?
If private well, provide Hea -Re ment form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Y/N
Items to be verified in the field:
If so, obtain proper
Inspector : Date:
I, / N Notes:
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Reviewer to complete the following:
Square footage of Use: �-.� U u
9/N J/
Permitted as: Q 6" 6 wl
Under Section:
Supplementary regulations section:
=P 0�v
'Parking formula: ��""
ch,4n 6IAMJ�S 4e
Required spaces:
Circle the one that ap li
Is parcel on septic or ublic sewer
Y/N
Will you be putting up a new sign of any kind?
Sign permit.
Permit #
7.nnina to PmmnlPtP the fnllnwinu-
iolations:
/N
f so, List: �
Prof s:
Y/
If so—, List:
Varia e:
Y /
If so, List:
SP's
Y N
If so, ist:
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3
CERTIFICATION THAT NOTICE OF THE
APPLICATION HAS BEEN PROVIDED TO THE LANDOWNER
This form must accompany zoning applications (Home Occupation, Zoning Clearance, Zoning
Administrator Determinations or Appeals, Sign Permits, Building Permits) if the application is not the
owner.
I certify that notice of the application;
[County application name and number]
was provided to the owner of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number by delivering a copy of the application in the
manner identified below:
V11,
Hand delivering a copy of the application to
[Name of the record owner if the record owner is a
person; if the owner of record is an entity, identify the recipient of the record and the recipient's
title or office for that entity]
on
Date
Mailing a copy of the application to
[Name of the record owner if the record owner is a person;
if the owner of record is an entity, identify the recipient of the record and the recipient's title or
office for that entity]
on
Date
to the following address:
[address; written notice mailed to the owner at the last known address of the owner as shown on
the current real estate tax assessment books or current real estate tax assessment records satisfies
this requirement].
c ) , S/ &j
Print Applicant Name
Date