HomeMy WebLinkAboutCLE200900095 Legacy Document 2012-08-31i�0
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Application for Zo!$1W Clearance
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CLE #
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Clearance = $35
OFFICE USE ONLY j
Check # G?, Date: �/ (�
7 Staff:
PLEASZoning
REVIEW ALL 3 SHEETS
Receipt #
-TA-KC EL�INFOIUUTi0
Tax Map and Parcel: t11 �00 -00 — 00-- 0SSAO Existing Zoning Oawn,4 �2Stc�trt�lc�Q��V,
Parcel Owner: —N M640-f 9(Au 0 VIV /,((i16 L�X—I
Parcel Address: 14' oo �c�Aw M ouyj-it,trl V(40 City (iV1 aA--kC Vt4 State zip ):)I
(include suite or floor) 1 St f--Lnaa q k 00 S-
PRIMARY CONTACT
M Cp✓I j"f"W C�-1 °�
Who should we call /write concerning this project ?G
Address: S 1 ' A EbA &4 cQ Q City Sfttn4&A State \fA— Zip ?:a IS
Office Phone: 0°2) 5-0 Cell # Fax # 70'�-la -24-5E -mail t�41-�un VCYhY.CDrr\
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name /Type: r, � y I D k V, �� P h l A l VS IS — Vl+q Vic .
Previous Business on this site !'C
Describe the proposed business including use, number of employees, number of shifts, available parking spaces, number of
vehicles, and any additional information that you can provide: b t G) N C yS 0,1 � N L e-
*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 '`f� Printed le �'f7 )
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, 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: ftnr"56i- 17 A,-, -r� 4L (kuj ci—���
c
Building Official � � fi���� �—� Date a o-
Zoning Official Date i
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
7 —.. a p
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.
0—/ N Tom(
Permitted as:
Y/N
Will there be food preparation?
Under Section: Pao
If so, give applicant a Health Department form.
Zoning review can not begin un i we receive approva - om -eat --
Dept. FAX DATE
up ementary regu bons section:
it R
Circle the one that applies
Is parcel on private well or public water?
Parking formula: /
( 12, 00 A4k
If private well, provide Health Department form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Required spaces: l
�' S l ( �-1 -0'
Y/N
Clearances:
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 pr p,e�Per�api�
Permit # (/
Zoning to comDlete the following:
Violations:
If so`Y.ist:
^offers:
If so, List:
Var' ce:
Y6
If so, List:
S 's:
/N
so, List:
Clearances:
SDP's
Revised 04/28/08 Page 3 of 3