HomeMy WebLinkAboutCLE201200221 Legacy Document 2012-12-20Application for Z(Vning Clearance
CLE
Pf,EASE REVEEW ALL 3 SHEETS OFFICE, USE ULY
checl - —I--.-- Dal. JL 1 A-
Receipt # Staff:
INFORMATION
Tax NJap sind Parcel: rsxisting zoning C—o
Plircel Owllm
Parcel CRY _C/-LIL/_Lav trlte
(include suite or floor)
PRIMAR
Y CONTACT
Who should we call write concerning this project?
-e tT,-, . r? ,4, 1
C i ty
State
Off-ice Phone,: W,12L-77 EZ - i na 7k e 7
APPLICANT INFORMATION
Check any that apply- Chavae of ownershin ChanL7e Of use Change of narrie L.-'Nlew lmsine.q.K i
p,
violis Business on this site—&- EW,2, f
cribe the proposed business including use, number of employees nu fts mailable parking er of
'This Clearance will only be valid on the parec-I for which it is approved. Ifyou change. invens;16; or move. the use to new location, a new Zoning
eartnea wiH b-, required.
I hereby certify that I own or have the mviler"s pamission to use the space indicated on this an lication. I also certify that the information provided
I p
is true and.11CCM ate (0 th S fruYUC)"Iedge."if-dve d the conditionsorapproval, and I understand tic i, and that I will abide by them,
a � re I
"ve "a 7e,
"ny'
accurate
r^, 3
Signature
Printed
-��I—A 1-1 —01N
A D 1A, i
P L INFORMATION
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App�roved as proposed
I ;Approved vvith conditions } a Denied
Backfiow prevention device and/o! current test data needed for this site, Contact ACSA,977-45llxj,1T
No physical site inspection has been done for this clearance. Therefore, it is not a determination of compliance With the existing
site plan.
]Tbis site complies with the site Plan as orthis (late.
Boilcling Mcial
Date 0
Zoning Official Date
Other official Date
f-0tility 91 A.1bemarle Department of Coiriniunity Development
401 mcintireRoad Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (434) 972-4,126
Revised 7/1/2011 Page 2.of 3
111011(c to Cornplete the follo"ving:
y /oil
Is U
Il' ligilwer's Repoli (CEIA) picket.
Ifio, give applicam a ccrtified
y ! —
rood preparation?
If so, giwe applicant a Health D6partmellt forti-1.
Zoninl rcvl(:w call 'lot b,'el;in uIllil Nye receive approval from Health
Dept. FAX DATE --- . ..........
Circle tile One th?f applies
Is parcel of) private well or 1) IA
lfprivate well, provide Healffi -, Iment ffirrij,
Zoninc, review can not bed in until we r"eive approval frotl: f-1, call th
Dept. FAX DATE
Circle the one that applies
Is parcel on septic or I =
Revie"Yet• to Complete the following:
Square footage, of Ulse;
4)!N
Penn, tied as: w AO-/
Underswiow— -2--2,.
Supplementary regulation's section:
Parking formtda:
Required spaces;
y1pIterns o be verified in the field:
XI N
Will you be putting up a new sign ofany kind? If so, obtairl proper
Sign permit.
Permit 111spectol, Date*
;totes:
'411 NT there be any new constructio:1 o
If so, ob-11
t e r Mt
perild 9
Zoning to complete the following:
Violations,
y 1
If so. ist:
. ... . .. . ...... .......
y
Ifiso ist;
SPIS:
Y ' ' N
i'iirtill c:
y 1
CI ea ra nW17--
....... ...... 4) —7
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Revised 711/2011 Page 3 of'3