HomeMy WebLinkAboutCLE200900030 Legacy Document 2012-08-27Application fo Zoning Clearance
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CLE # 6y Q
❑ Zoning Clearance = $35
OFFICE E NLY
Clerk_# Date:
PLEASE REVIEW ALL 3 SHEETS
Receipt # j1l,i Staff:
PARCEL INFORMATION
Tax Map and Parcel: Existing Zoning
Parcel Owner:
Parcel Address: City State Zip
(include suite or floor)
PRIMARY CONTACT d l
Who should we call/write concerning this 1i ;5
nproject?
Address: 3'11U V�,i ,4� ,rs%3,. City Lv,:,k State Zip
Office Phone: S� Cell %�'� Fax' a, bA E -mail LA
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change ofy name New business
1
Business Name /Type:: 11_\ Ll , ^�-Lt A)
Previous Business on this site
Describe the proposed business including use, number of employ s, number of shifts, available parking spaces, number of
vehicles, and any additional information that you can provide:lA
*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 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 Printed..
APPROVAL INFORMATION
[ ] Approved as proposed ;-I 'Approved with conditions [ ] Denied
[ ] Backflow prevention device and /or current test data needed for this site. Contact ACSA, 977 -4511, xl 19.
[ ] 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 d te. / p
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Notes: lu1, �� -.4k� 6 2,��1 d �>/l� /1 /J j✓� 2SS
Building Official Date
Zoning Official Date �A /o y
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 04/28/08 Page 2 of 3
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Intake to complete the following:
Reviewer to complete the following:
Y / N
Square footage of Use:
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y / N
Permitted as:
Y/N
SP's:
Y/N
If so, List:
Will there be food preparation?
Under Section:
If so, give applicant a Health Department form.
Zoning review can not begin until we receive approval from Health
Supplementary regulations section:
Dept. FAX DATE
Clearances:
Circle the one that applies
Parking formula:
Is parcel on private well or public water?
If private well, provide Health Department form.
Zoning review can not begin until we receive approval from Health
Required spaces:
Dept. FAX DATE
Y/N
Circle the one that applies
Items to be verified in the field:
Is parcel on septic or public sewer?
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Inspector : Date:
Y / N
Notes:
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
7nninor to emmnlete the fnllnwinff-
Violations:
Y/N
If so, List:
Proffers:
Y/N
If so, List:
Variance:
Y/N
If so, List:
SP's:
Y/N
If so, List:
Clearances:
SDP's
Revised 04/28/08 Page 3 of 3