HomeMy WebLinkAboutCLE200900120 Legacy Document 2012-09-10Application for Zoning Clearance
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CLE # - I
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Zoning Clearance = $35
OFFICE USE ONLY V
Check # % I!ate-
Receipt # Staff:
PLEASE REVIEW ALL 3 SHEETS
PARCEL INFORMATION 2 /
Tax Map and Parcel: 13q C `1 / Existing Zoning
V bmi I G�V ✓
Parcel Owner: /���C -�„'
Parcel Address: / / City 11y,/ State Zip
1 1 Uvoo�
(include suite or floor)_
PRIMARY CONTACT
Who should we call /write concernin g this p ro'ect? Mad ( -,n a
�, /
Address: � 5a _r Icv�oal d � City �� estate VO . Zip _Tz
Office Phone: &3je q7 Cell # 4'3 F'!(1`f 7ggaax # E -mail
APPLICANT INFORMATION
Check a-nyy that apply:_ Chang nershi Change of use Change of name New business
/Typ
B�sTame
Previous Business on this site
Describe the proposed business including use, number of emplo ees, number of shifts, available parking spaces, number of
7 5'111S,
vehicles, and any additional information that you can provide:��e �,�rIV1�%1 C'(Yl(��alfS.
Si'101i ioa fP kr
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*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 y knowje dae. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature _ Printed �AwL�V�
APPROVAt 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 �omplies with the site plan as of this date.
Notes
Building Official Date
Zoning Official 6 Datei
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
1 � 1
In
Intake to complete the following:
Reviewer to complete theAfollowng:
Y /
us�'Cn
Square footage of Use:
Is LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
M/ N
'
�Y/ N
rmitted as: P 1
J
ill there be food preparation?
Under Section: I
If so, give applicant a Health Department form.
Zoning review can not b gin until we�j'eceive approval from Health
Dept. FAX DATE (;0
Supplementary regulations section:
Circle the one that applies
Parking formula:
Is parcel on private well or ublic water?
If private well, provide Health Department form.
Zoning review cannot begin until we receive approval from Health
Required spaces: /
Dept. FAX DATE
/QV
Circle the one that applies
Items to be verified in the field:
Is parcel on septic o public sewer
N
�V11I you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit # - -
Inspector : Date:
Y / QT4 :Notes:
Will re be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
7nninv to rmmnlPtP the fnllnwinv-
Vi ons:
Y/N
If so, List:
Proffers:
Y/(9
If so, List:
Varii ce:
If sd, ist:
SP's:
If so, List:
Clearances:
SDP's
Revised 04/28/08 Page 3 of 3