HomeMy WebLinkAboutCLE200900195 Legacy Document 2012-10-15Application for Zoning Clearance
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CLE # IW"l - lqt5-
OFFICE USE ONLY
[29 Zoning Clearance = $35
Check # q Date:
PLEASE REVIEW ALL 3 SHEETS
Receipt # d9gt) Staff. u-04
PARCEL INFORMATION
Tax Map Parcel: U% 9 Od ^ Q @ - Q 0 -- O 1 -% U Existin Zonin
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Parcel Owner: Crc7- Ac--&T LfA-S 'TG-X n/ %I 6-A,- " 2. m •Q,n a.
Parcel Address: 3 q K J ,' zdP r CTA- City C 6AZ-U)Z7 CsfJ1U e State VA- Zip ZZI d )
(include suite or floor)
PRIMARY CONTACT
Who should we call /write concerning this project? go 6 (,-7z-r G(A c, -( ce 2 s
Address : 32'� 9 6 rl-Ao- '`1 o T -e gQ City CI4' pcC Q- State VA- Zip
1134 -116k- p
Office Phone: c 3�1 � Z q C - 5131 Cell # ci Vv C Fax # E -mail l� (AIg ry'L-- %}t6LW%
CA
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
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Business Name /Type: Vd 1 !�Cdw T S 01^ /JVIN tiXi C A LC
Previous Business on this site
available
Describe the proposed business including use, number of employees, number of shifts, available�arking spaces, number of
vehicles, and any, additional information that you can provide: C-,aj A +ii SCr►Z CC--
C i1 Q% t T w A -t —rZ t: l'
*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 t e best of my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
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Signature �- Printed /� P�?t? 'T. WA C '% t-r
APPROVAL INFORMATION
I M Approved as proposed [ ] Approved with conditions [ ] Denied
Backflow device test data for this Contact ACSA, 977 11 -4-°
]] prevention and/or current needed site. -4511, x++9-
[ ] 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 l t
Zoning Official Date
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
(13-
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 #
7nninu to emmnlete the fnllnwinu:
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