HomeMy WebLinkAboutCLE200900182 Legacy Document 2012-10-18Clearance_
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Application for ZoniT)W_
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CLE # '�iO �
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Zoning Clearance = $35
OFFICE USE ONLY
Check # -L Date:
PLEASE REVIEW ALL 3 SHEETS
Receipt # Staff:
PARCEL INFORMATION
Tax Map and Parcel: 679'oo --OO ° 60 _ V 3 F C5 Existing Zoning
Parcel Owner: (��%
_ ,S� 170 I ,/j
Parcel Address: 6, 1} Pe, k r) r W e(o �7 Prl(t -xl City F !, %o J /C5V - Ile State V t Zip
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project?
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Address : C�30 p QA f�Q �(� ,ii11Q . Sin llb City P UO) (,.b- 1 1 State Zip ZzR P
Office Phone: "7559 Cell # f K/A _ - Fax # -' Da E -mail �/►/lpd(�fn�_ptiU' o sift
APPLICANT INFORMATION
Check any that apply: Change of ownership of use Change of name New business
+Change
Business Name/ Type: Q rnnOC�yc ?o1 r, (] Vl 6 9,W19,hb�i TmqdJZ C!L>
Previous Business on this site �u(�� 0, y1
Describe the proposed business including use, number of employees, number of shifts, available parking spaces, number of
vehicles, and any additional information that you can provide: Vluz em a .
ob .vv►, Pt ti ai A i
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 a best of My knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature / , Printed
APPR6VAL INFORMATION
[ Approved as proposed [ ] Approved with conditions [ ] Denied
[ ] Backflow 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
Zoning Official Date Z I D
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/N
Is LI, HI or PDIP zoning? If so, give applicant a Certified
Eng eer's Report (CER) packet.
Y/
Wi I re be food preparation?
If o, 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 pupl c ter?
If private well, provide Healtkpq urtment form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applies_
Is parcel on septic or p is s wer?
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit. —\
Permit # j
Y/N
Will there be any new cons ction or ren vations?
If so, obtain the proper Pe mit. 4
Permit #
Zoning to complete the following:
Reviewer to complete the following:
Square footage of Use: 1400
`imitted as:
Under Section: o� 5 ` I
Supplementary regulati(T t
Parking formula: 1 P OD .W-c)
Required spaces:
Y/N
Items to be verified in the field:
Inspector :,
Notes:
Date:
Violations:
Y/
If s , 'st:
Proffers:
N
f o, List:
Varia
Y/
If so, ist:
s:
Y N
YfL, List:
Clearances:
SDP's
Revised 04/28/08, 10/13/09 Page 3 of 3