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CLE200900110 Legacy Document 2012-09-10
Application for Zoning learance CLE # /_OO C(- I1� I*- Zoning Clearance = $35 OFFICE USE ONLY �-7 -� U p Check #� Date: / , PLEASE REVIEW ALL 3 SHEETS Receipt # `% 6,5 416✓ Staff: r %7 /i /rP�✓ PARCEL INFORMATION - - - - - -- Tax Map and Parcel: , joyf�-04-oa -D 181' 40 Existing Zoning �IY!/Y/. 1'9iA�/,l rif�SS� Parcel Owner: '41 w se r Rio f( /L Z, /_ Z-e -0 ay e,vl Z*L %IYI��I/ is��.✓T L� Parcel Address: 1-9,6,g /7/0 Illa— elrA. City ei� &a7- ;Z5V141,0- State V4 Zip Q?J. - - -- - - -- - - (include suite or floor) -- — PRIMARY CONTACT Who should we call/write concerning this project? Address : 23b� J • �•�% J�� S% City CA0,6 OfM'L State FL Zip33 g I4- Office Phone: Cell# yya ?3&Fax #q /e q,3/ -337 -mail �$I/IY� QD�6OA4 APPLICANT INFORMATION Check any that apply: Change of ownership Change of use Change of name New business Business Name /Type: 4maictut 6�erzaL.. F /tjA-A)Cc Previous Business on this site lei, J7. &I 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: FliiVAea O•Fg Cq /b Z-Mq -o 9"Ez-3 *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 tlAt I own gr have the owner's permission to use the space indicated on this application. -I also certify that the information provided is true and accur t to the b t of my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them. 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 sitt complies with the site plan as of this date. Notes: OCI l 0_q W/ Building Official r . 'Lc-_ Date Zoning Official Date 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 -M - - -- -- -Intake to complete the following: Y/© Is use in LI, HI or PDIP zoning? Engineer's Report (CER) packet. If so, give applicant a Certified Y / WilQtere be food preparation? - If so, give applicant allealth- Depafinent form. -_ T— 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 ublic water? If private well, provide Healt Department 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 ublic sewer? P/ N Will you be putting up a new sign of any kind? If so, obtain proper Sign permit. Permit# - -- - -- - -- - - -- - YO/ N Will there be any new construction or renovations? If so, obtain the roper Permit. Permit # —, 1,C, ZOninQ' to complete the followinlr: Reviewer to complete-the following : - - - -- -- - - - -- -- - - - -- - – - -- - Square footage of Use: /N - mitted as: etc < Under Section: Supplementary regu ations section: 1/L _ Parking formula: Required d-spac -- - - - -- -- -- -- Y/N Items to be verified in the field: Notes: Date: Viola ' ns: Y/ If s ist: Proffers: /N f so, List: Variance: Y/ If �ist: n SP's• YID If so, List: Clearances: SDP's Revised 04/28/08 Page 3 of 3