HomeMy WebLinkAboutCLE200900031 Legacy Document 2012-08-27Application for Zoning Clearance
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CLE #
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OFFICE S' ONLY
❑ Zoning Clearance = $35
Date:
PLEASE REVIEW ALL 3 SHEETS
Receipt # Staff: `
PARCEL INFORMATION p
— Existing Zoning
Tax Map and Parcel: (�
Parcel Owner:
Parcel Address: City State Zip
(include suite or floor)
PRIMARY CONTACT
project?
Who should we call /write concernin g this roject.�
Address : 8.')1 m 2— City e,�-,j State �) C. Zip
Office Phone: Cell Fax EW-gl (A E -mail L
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name /Type= 5�,
Previous Business on this site
Describe the proposed business including use, number of emplo ees, number of shifts, availa a parking spaces, number of
vehicles, and any additional information that you can provide: tac I- Awz lzw�
*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.
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Signature Printed S. ��:ac7,.jL,rC)V i?
APPROVAL INFORMATION
[ ] Approved as proposed [ %] Approved with conditions [ ] Denied
[ ] Bacicflow 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 c mplies with the site plan as of this date.
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Notes: fa0 cen IhA Y "y-/j 1�4,9A) .3
Building Official Date ((O �
Zoning Official Date 2,14 2
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
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
Will there be food preparation? Under Section:
If so, give applicant a Health Department form.
Zoning review can not begin until we receive approval fiom Health Supplementary regulations section:
Dept. FAX DATE
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 ltind? If so, obtain proper
Sign permit.
Permit #
Y/N
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
7nnincr to emmnlete the fnllnwinu:
Inspector:
Notes:
Date:
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