HomeMy WebLinkAboutCLE201200243 Legacy Document 2012-12-27Application for Zonin Clearance
5
CLE # 2dV - 2_
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PLEASE REVIEW ALL 3 SHEETS
OFFICE USE ON Y
Check #% Date:
Receipt # 5Al Staff: —Yj ��
PARCEL INFORMATION
�- 0 (— 6 AP to" (b rr �Gl-#'
0 q I Zoning
Tax Map and Parcel: �+ �-� Existing
cel: 0
Parcel Owner: (*74W G` vi°) Qo
r
I 3 j k �n. Cit ��� State
t,
Parcel Address: ►o y y-
(include suite or floor)
PRIMARY CONTACT
Who should we call /write concerning this project? 1� IiLJ
Address : ��� /,On'2 (A)M& L&e City�ma r5 2G- State Zip ZZIS�
ffice Phone: + I dR Cell #Y3Y #Y3 wa Fax # E -mail �`1 l✓►+ (,tii"
Owl 50 -eAX.
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of us/e Change of name New business
n/Y7i ��'1
Business Name /Type: `J4 ✓�o ,r
Previous Business on this site
Describe the proposed business including use, number of employees, fflumber of s ' t , available parking spaces, number of
vehicles, and any additional information that you can provide:
*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 /6'Lk4
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, 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:
�— Date (f (t
Building Official
/
Zoning Official Date Z��
Other Official Date
County of Albemarle Department of uommumty ueve>opment
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
Revised 7/1/2011 Page 2 of 3
Intake to complete the following: hN,
Y /
Reviewer to complete the following:
Square footage of Use: Oy
Is use n LI, HI or PDIP zoning? If so, give applicant a Certified ,Engineer's Report (CER) packet. f _ as: � ; ✓ ,lam I 'C� ) C/ A C.{ �
Y / t e ,J
Will re be food preparation? Under Section: Z7 ,'L, `y 2L)
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
Circle the one that applies
Is parcel on private well or ublic water
If private well, provide Health epartment form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that appli
Is parcel on septic o public sewer
Y /�Will ou be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y /
Will �tere be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
7..,,;,,.t +n nmm ln+a +ha fnllnwina-
Parking formula:
Required spaces: / 1
Y/N
Items to be verified in the field:
Inspector :
Notes:
Date:
.� -- - - - - - -- - -- - -- - - - -- -
Violations:
Y /Iq
If so( �t:
Proffers:
Y
If o, L' t:
Varian e:
Y/N
Ifs , ist:
SP's:
Y/
If s ist:
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3
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