HomeMy WebLinkAboutCLE201200175 Legacy Document 2012-08-27Application for Zoni:n Clearance
CLE #
PLEASE REVIEW ALL 3 SHEETS
OFFICE USE ONLY
Check # J5&52_ Date: 6- 6.17
Receipt # Staff: —rfv�T—
PARCEL INFORMATION
Tax Map and Parcel: Existing Zoning
Parcel Owner: S US=,
Parcel Address: t (4 00,, � � `` � QA City (' �-t�- "tAA 3ta� VA Zip el
(include suite or floor)
PRIMARY CONTACT � �
N\a," Y_
Who should we call/write concerning this project? 1�--0,
Address: CitykAsis -i State VA Zip'
Office Phone: Cell #!5,5J'? Fax # E -mail d rf+oi
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name /Type: °17 -T022
Previous Business on this site
Describe the proposed business including use, number of employees, number of shifts, available arking spaces, number of
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vehicles, and any additional information that you can provide: . -2.-`l'
vt� C m per v _<'Anw cy _a. C, vy-e
*This Clearance will only be vali on the parcel for which it is approved. If you change, intensify or ove the use a new location, a new Zoning
be
Clearance will 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
3 fi' P
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 k-1 Printed ou"
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 detenninafion of compliance with the existing
site plan.
[ ] This site complies with the site plan as of this date.
Notes:
Building Official v Date x-17 - ► Z-
Zoning Official Date
Other Official Date
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
Revised 7/1/2011 Page 2 of 3
0-OA/1
r
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Intake to complete the following:
Y/<P
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Will t ere 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 public water?
If private well, provide Health Department form,
Zoning review can not begin ritil we receive approval from Health
Dept. FAX DATE �3
Circle the one that applies t
Is parcel on septic or public sewer? J I A
(V/ N
Will you be putting up anew sign of any hind? If so, obtain proper
Sign permit.
Permit #
Y /G)
Will there be any new construction or renovations?
If so, obtain ft proper Permit. ' ` I K 6' Q
Permit # `lam L�
O
_T Fk 12111 tx
- -- -- . , 6 .L r n ..,:,,,..
Reviewer to complete the following:
Square footage of Use:�i� lC� 7S,
>// N
Permitted as: �� ri�-H' `l l �%h:�
Under Section: iCM . I�4P
Supplementary regulations section:
Parking formula:
Required spaces:
Y/N
Items to be verified in the field:
Inspector : Date:
Notes:
uvaaaaa
Violations:
O/N
If so, List:
Proffers:
Y/
If so, ist:
Varia e:
Y/
If so, ist:
SP's:
Y
If st:
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3
1, V 11
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