HomeMy WebLinkAboutCLE200900128 Legacy Document 2012-09-10Application for z v` _'InLy Clear ance�
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CLE # D
`�RGIN�n
OFFICE USE ONLY Q I
Zoning Clearance = $35
Check # Date: (J
PLEASE REVIEW ALL 3 SHEETS
Receipt # Staff: 2617U
- PARCEL INFORMATION
Tax Map and Parcel: lb-17t>6 Existing Zonings
j y�, ,� n
Parcel Owner: VI / Al L-.-W : GO•� -/ O — W j11�'r"' IBC ,
Parcel Address: Z!pO City State VA Zip 22 /
(include suite or floor)
PRIMARY CONTACT
Who should we call /write concerning this project ? /L /GAG{ L. %LDD'r HDA#z/5 P7,e l�6
Address: City 720A/40JJ State "A9y14A1r_-> Zip 212
Office Phone: //J ) ew-110 d Cell # Fax A/P h j./ /703 E -mail trp_ Hrg a �-4 . �o�!
- APPLICANT INFORMATION - - - -- - - - - — - - - -- - - - - - - - -- - - - -
Check.any that apply:' Change of "ownership ' ` Change ,of use." " Charige,!of name , ,Nerv:busmess'.
Business Name /Type: VriL/")y
Previous Business on this site
Describe the proposed business including use, number of employees, number of shifts, available parking spaces, number of
VZW /UA/I-r 4,e-r E
vehicles, and any additional informatio that you can provide: r;giMf-- n4tiF'MEN 4r- PAJ
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AfIT7_C0_01- 740-17P4 As s w�/•
*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 pennission to use the space indicated on this application. I also certify that the information provided
is true and accurate the best of my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
I�to
Signature ;*:a . G Printed %ylG� IZt�t�r
°APPROVAL INFORMATION
[ ] Approved as proposed [ : ] Approved with conditions [ ]:Denied
[ ] Backflow prevention device and/or current test data needed for this ;site. " Contact ACSA, 977 - 451.1; 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 s' e complies with the site p an as of this date, �j" �
- 60 /
Notes: ,�' Gl /
Building Official Date 0'1
Zoning Official bate oil .
Z—
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: Reviewer to complete the following:
Y /1N Square footage of Use: p�•
Is us I, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet. Y / N
J rmitted as: V r�
Will`t�fefe be food preparation? Under Section:
If so, give applicant a Health Department form. f
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Zoning review can not begin until we receive approval from Health Supplementary regulations section: j
Dept. FAX DATE
Zoning to complete the followiniz:
Violations:
Y
If so, ist:
Circle the one that applies
Is parcel on private well or p�u lic w ter?
Parking formula:
!TU
If private well, provide Healt artment form.
Zoning review can not begin until we receive approval from Health
Required spaces:
SP'
Y�)ist:
If
Dept. - FAX DATE
Y
Clearances:
Circle the one that app l' s
Items to be verified ' he field:
Is parcel on septic or lic sew r?
Uat 02
Y/N
el
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 an6newco trnction or r enovations?
If so, obtain the mit.
Permit #
Zoning to complete the followiniz:
Violations:
Y
If so, ist:
Proffers:
Y
If ist:
Vafia ce:
Y�
If ist:
SP'
Y�)ist:
If
Clearances:
SDP's
Revised 04/28/08 Page 3 of 3