HomeMy WebLinkAboutCLE200900119 Legacy Document 2012-09-10Application for Zoning Clearance
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CLE # �i- M
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Zoning Clearance = $35
OFFICE USE O
Check # Date: ��� ��
PLEASE REVIEW ALL 3 SHEETS
Receipt # _ -7 Staff :_
PARCEL INFORMAQN
66 l
Tax Map and Parcel: Existing Zoning(,()
Parcel Owner:
r, I " "L� • N,Q
Parcel Address: 2,50---4- `UM vl ()AYy ►'"1 �' City C r �L�.� State
(include suite or floor)
PRIMARY CONTACT
Who should should we call /write concerning this project?
Addressjs�8- CA*ff>f�� �' V ity fi State V Zip ) 2Z
Office Phone: Z(— Cell # �yo Fax � �7" E -mail V � �
-7 � Z�— (n') �
APPLICANT INFORMATION
Check any that apply: Change of use name New business
�' /Change toff
��,�,.�Change�of�o"w'nership
rvC' P14V4- '1` Jw�
Business Name /Type: 1 1\ C. �Vv
Previous Business on this site
Describe the proposed business including use, number of employees, n tuber of shifts, available arking spaces, number of
vehicles, and any addi_ tignal information that you can provide: — o
*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 own o ave th owner's permission to use the space indicated on this application. I also certify that the information provided
is true and urate to the e of nowledge. I have read the conditions of approval, and them, and that I will abide by them.
,I /understand
Signature Printed 4111 1
APP AL INFORMA ION
[ pproved 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 comp es with t ie sit la as of this date.
Notes:�� /c d� Lzrte, G7-�
Building Official Date
Zoning Official Date g ID/0
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
:211
Intake to complete the following:- -
Reviewer to complete the following: -- -
Y / N��
Is use`'�fn�LI, HI or PDIP zoning? If so, give applicant a Certified
Square footage of Use: b!
Engineer's Report (CER) packet.
/ N �(�-�
Germitted as: fy'��['1 141Pi
Will lliere be food preparation?
Under Section:f •OC�. l
If so, give applicant a Health Department form.-- - -
- - _ - - - - - - - - - -
Zoning review can not begin until we receive approval from Health
Supplementary regula ons section:
Dept. FAX DATE
(/Ja
Circle the one that applies
Is parcel on private well or is wa er?
Parking formula /,
Required spaces:
If private well, provide H t e ment form.
Zoning review can not gin until we receive approval from Health
Dept. FAX DATE
Imo/
Y/N
Circle the one that app 'es
Items to be verified in the field:
Is parcel on septic or pu is e e ?
Y/N
Will you putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit # - -- - -- - - - -- -- - --
Inspector : Date: -
Y / N
Notes:
Will there be any ew construction or renovations?
If so, obtain the roper Permit.
Permit #
7nnin4 to cmmrilPtP the fnllnwinu-
Vio ns:
Y
If LO J-st:
Prof ers:
Y/
Ifs L'st:
Varian e:
Y K N/
Ifs , ist:
SP's:
Y(7
If` D4ist:
Clearances:
SDP's
Revised 04/28/08 Page 3 of 3