HomeMy WebLinkAboutCLE200900015 Legacy Document 2012-08-27Application for Zoning Clearance
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CLE # � o� 4,
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SRC INS
Zoning Clearance = $35
OFFICE USE ONLY
Check # 11,76500 Date:
PLEASE REVIEW ALL 3 SHEETS
Receipt # -7,3706 Staff: �a
PARCEL INFORMATION y/
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Tax Map and Parcel: //4 Existing Zoning
Parcel Owner: 61WI A _17y of VlR 10,11A �- 'yy,"41Vi71U•,✓
Parcel Address: Yd X • (• //V'-/' I)RIllf City (AWZ(A770 �'«Cf State i� JR (INiA Zip) -Lg 6'
(include suite or floor)
PRIMARY CONTACT T /
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Who should we call /write concerning this project?
Address AF10e ���+^'7� City 011,1170 7-701'11'r State VA ZipZZ.7 b
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Office Phone: y1 /o Z' 'If Vkell # f ?/ q6- Fax # 712 " �o E -mail c.� IA/ 6k/
APPLICANT INFO ION
Check any that apply: Change of ownership Change of use Change of name New business
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Business Name /Type: /C/c�C� "17
Previous Business on this site J?P^e
Describe the proposed business including use, number of employees, number of shifts, available parking spaces, umber of
vehicles, and any additional information that you can provide: bFF /Gf' L�%Qf -fO ✓�/�
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*This Clearance will only be valid on the parcel for which it is approved. If you change, intensify or move the use to anew 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 laiowledge. I have ad the conditions of approval, and I understand them, and that I will abide by them.
Signature Printed �ii% %��% �/`J�l,%�✓"
APPROVAL INFORMATION
[ Approved as proposed [ ] Approved with conditions [ ] Denied
[ ] Backfow prevention device and /or current test data needed for this site. Contact ACSA, 977 -4511, x119.
[ �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: 'ZMA 2 00e-)--10,
Building Official - Date
coning. Official ° Date of
Other Official Date
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville,,VA 2.2902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
- Revised 04/28/08 Page 2 of 3
Intake to complete the following:
Is /�Is a I, HI or PDIP zoning?
Engineer's Report (CER) packet.
If so, give applicant a Certified
Y /
Wi e 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 pu em�cnt r?
If private well, provide Health form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that app
Is parcel on septic or ublic se er?
Reviewer to complete the following:
Square footage of Use:' �.�/
Y / N �l (-f'I
Permitted as: ��
Under Section:
Supplementary regulations section:
Parking formula:
Required spaces:
Y/N
Items to be verified in the field:
Y/N
Will you btnew w sign of any kind? If so, obtain proper
Sign perm
Permit # Inspector : Date:
Y / N Notes:
Will there truction or renovations? ��~ If so, obtamit. r � 0 '
Permit #
Zonin2 to complete the following:
Violations:
If so, List:
-so; tst: )-OA D' yf Id
Vari ce:
Y/
If so, List:
ASP
� /N
Aso, List:
Clearances:
SDP's
Revised 04/28/08 Page 3 of 3
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