HomeMy WebLinkAboutCLE200900177 Legacy Document 2012-10-11Application for Zoning Clearance
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CLE # � '( — I
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Clearance = $35
OFFICE USE O LY
Check # / Date:
-7 Z 04ftel
PLEAZoning
REVIEW ALL 3 SHEETS
Receipt # LO S Staff:
PARCEL INFORMATION /� - �p
Tax Map and Parcel: -/2 7 FOO — 0 -d � —031 � r Existing Zoning_P, 1), I VN 6
Parcel Owner: d
/
Parcel Address: b 7 6� �i' ��� tTt' G� 11 City/ / �a�l l�S✓; Pe -State (� Zip 22
(include suite qr fl or) 2
PRIMARY CONTACT \ `
Who should we call/write concerning this project? Y �- \ /
qq �7
y, '1
2 � �\ N'w-A' , � �(�
Address : 0 IV `t �Cx �� City mate \ Zip I
Office Phone: # Z,5" -LJ 1 L�Fax # da E -mail }� C%% • Y��'��
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APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
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Business Name/Type: (10'\ . 0% Lod � u
Previous Business on this site
Describe the proposed business including use, number of employees, number of shifts, avail ble parking spaces, number of
ve icles, and any additional information that you can provide: Qt�n �� �� �}l QZ` d Sc p(i✓i'T
• �� xev VA c Q S
*"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 my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature Printed
OVAL INFOR
AP INFORMATION
[ Approved as proposed [ ] Approved with conditions [ ] Denied
] Baclflow prevention device and/or current test data needed for this site. Contact ACSA, 977 -4511, x117.
[ ] 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 o Z o
Ira
Zoning Official Date �� -� 07
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, 10/13/09 Page 2 of 3
Intake to complete the following:
Y/
Is use LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
C
Y/
Will e be food preparation?
If so, give applicant a Health Department form.
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 pu is ater?
If private well, provide Health partment form.
Zoning review can not begin until we receive app_ roval from Health
Dept. FAX DATE
Circle the one that app ' s
Is parcel on septic or lic 2er?
Y/N
Will you be putting dp a
Sign permit.
Permit #
Y/N
Will there be any new
If so, obtain the prope
Permit #
sign of any kind? If so, obtain proper
v or�vneti.
Zoning to complete the following:
Reviewer to complete the following:
Square footage of Use: � 3 r}-
N
fitted as: O�j R -(�
Under Section:
Supplementary regulations section:
Parking formula: t /j- 0 0 44-
Required spaces:
to be verified in the field:
Inspector:
Notes:
Date:
viol"* ns:
Y
Flist: If
offers:
/ N
If so, List:
V an e:
Y N
Ifs ist:
' •
Y/
f so, List:
Clearances:
SDP's
Revised 04/28/08, 10/13/09 Page 3 of 3