HomeMy WebLinkAboutCLE200900139 Legacy Document 2012-10-01FM
Application for Zonin Clearance
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Zoning Clearance = $35
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PLEASE REVIEW ALL 3 SHEETS
Staff :
PARCEL INFORMATION /
Tax Map and Parcel: 0-7sx) • 00 •00 ' d��CC� Existing Zoning 14C.
Parcel Owner: 5 ?j 7atr rl.p -, ��
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Parcel Ad _3b /V�lJI,•)Vj� SL City I �- State 1/p.. zip L7
(include suite or floor)
PRIMARY CONTACT
Who should we call /write concerning this project? QA L J
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Address 111575, bt44 , Yn ,o • City State 0. Zip Z7 _+
Office Phone: C_ 3 Cell # • It f Fax # E -mail
APPLICANT INFORMATION
Check any that apply: of ownership Change of use Change of name New business
� jChange
Business Name /Type: LJf� '� ` ✓ r Wv� •�.
Previous Business on this site ��y►n.�,
Describe the proposed business including use, number of employees, number of shifts,lavailabl Perking space ,number of
vehicles, and any additional information that you can provide: '�p �� �j1�., 6 t
*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 'have the owner's permission to use the space indicated on this application. I also certify that the information provided
is true and accurate WARe Uest of m knowledge. I have read the conditions of approval, an understand them, and that I will abide by them.
Signature Printed M
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, xl 19.
[ ] 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.
Notes:
Building Official Date
Zoning Official DateZ�/
Other Official Date
County of Albemarle Department of Community Development
401 McIntire Road Cliarlottesville; 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 / N
Square footage of Use:
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y / N
Permitted as:
Y/N
SP's:
Y/N
If so, List:
Will there be food preparation?
Under Section:
If so, give applicant a Health Department form.
-
Zoning review can not begin until we receive approval from Health
Supplementary regulations section:
Dept. FAX DATE
Clearances:
Circle the one that applies
Parking formula:
Is parcel on private well or public water?
If private well, provide Health Department form.
Zoning review can not begin until we receive approval from Health
Required spaces:
Dept. FAX DATE
Y/N
Circle the one that applies
Items to be verified in the field:
Is parcel on septic or public sewer?
Y/N
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 any new construction or renovations?
If so, obtain the proper Permit.
Permit #
7nninv to emminlotP the fnllnwin¢-
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