HomeMy WebLinkAboutCLE200900098 Legacy Document 2012-08-31ter,/ 1
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A plication for Zonin learance
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CLE#__,,70��q—qv
Zoning Clearance = $35
OFFICE USE ONLY
Check # Date: ��� °�
PLEASE REVIEW ALL 3 SHEETS
Receipt # 747 77.E Staff: zy
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PARCEL INFORMATION. �
Tax Map and Parcel: (�' � -C'� � °" c� � 1 � C�isting Zoning
Parcel Owner: S,CJ � "
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Parcel Address:D �� c'Y��V >�.�' `. City ` �/�V�� State Zip c�
(include suite or floor)
PRIMARY CONTACT
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Who should we call /write concerning this project? 1E, -
Address : r�%�? ��C- irY \�1f� ?��rL A-K L City C_. I �l�l W State Vv"" Zip `a;)�1
Office Phone: `iNL cell # Fax # E -mail
APPLICANT INFORMATION
Check any that apply: of ownership Change of use Change of name New business
' ,Change
Business Name /Type:
Previous Business on this site
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:
*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. , y.- -0� ,R3_Q
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 two the best of my kno ledge. I have Tread the conditions of approval and I understand them, and that I will abide by them.
ac i' Printed nakv�o�_,,
Signature
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. ,�// / j� / d
r�%GI ��
Notes: %p �✓1- ���� -F3 b�'� :91
Building Official / Date
✓�>r Date
Zoning Official e
U
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:
Is d e-ifi 1, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y Nl
WiTFI 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 Healt Dep�i artmmen form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applies
Is parcel on septic or public sse_we_ r?
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y/N
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the following:
Reviewer to complete the following:
Square footage of Use:
Y/N
Permitted as:
Under Section:
Supplementary regulations section:
Parking formula:
Required spaces:
Y/N
Items to be verified in the field:
Inspector : Date:
Notes:
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