HomeMy WebLinkAboutCLE200900047 Legacy Document 2012-08-27OFFICE USE ONLY
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Revised 04/28/08 Page 1 of 3
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Application for Zoning Clearance
CLE # 900? — y ' 1
OFFICE USE ONLY
Zoning Clearance = $35 Check #2W673 � �.1• Date:
PLEASE REVIEW ALL 3 S ETS Receipt # Staff.
PARCEL INFORMATION
Tax Map and Parcel: 1 r C t Existing Zoning
Parcel Owner: jjl l �pp�II_ �/ (L t
Parcel Addressdll.J�}o��4nlQt)k 11ft! I, Ci 3 State �� Zip��q�
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project.
Address: )9 1 4 ' City Zip
Office Phone: Cell # Fax #10, E -mail
v
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use _Change of name New business
Business Name/Type:
Previous Business on I
Describe the proposed business including use, number of empl
vehicles, and any additional information that you can provide:
"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._
of
I hereby certify that I o or pave [lie owner's permission to use the space indicated on this application. I also certify that the information provided
is true and ac rate to a be t of my nowI dg I have read the conditions of approval, and I understand them nd that I will abide by them.
' / /o
Sign to t/ Printed
APPROVAL INFORMATI
,[If Approved as proposed [ ] Approved with conditions [I Denied
[ ] Backflow 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 witli the existing
site plan.
[ ] This site complies with the site plan as of this date.., .
Notes:
Building Official �c�.--- ��5"��''�'��-'�'`�\., Date
Zoning Official �' � ; Date
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OFFICE USE ONLY
Other Official
Page 3 of 4
Date
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 9724126
Revised 04/28/08 Page 2 of 3
Page 3
Intake to complete the following:
Y/a
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y
Wil 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
Reviewer to complete the following:
Square footage of Use:
Y/N
Permitted as:
Under Section:
Supplementary regulations section:
Circle the one that applies - -.- __ -T
Is i
Parking formula:
parcel on private well public
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 aplies�
Items to be verified in the field:
Is parcel on septic p6tilic 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 #
Zoning to complete the following:
Viol ons:
Proffers:
If so, List:
YscN
Yl
If ist:
Variance:
SP's:
Y /v
If List:
Y(./
IfPList:
so,
Clearances:
SDP's
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