HomeMy WebLinkAboutCLE201300004 Legacy Document 2013-01-11Application for Zo ing Clearance
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PLEASE REVIEW ALL 3 SHEETS
Check # Date:
Receipt # Staff:
PARCEL IN'F'ORMATION
Tax Map and Parcel: 04 C> A-e) -- r7 q -Co-n 9 f'OU Existing Zoning I�ttS�nlr,�SS c? >d� i�L 'i73tU�
Parcel Owner: Tlr'YytiR S 'j-t 1� P' �f
Parcel Address: Gi ,1S 022) City c"- #A4'2-1Q KVW1 Otate ZipZl ,
(include suite or floor)
PREM"Y CONTACT
Who should we call/write concerning this project? 7 U P% i _ �4-1 4: A u
Address:��� ,� 119•M /ie -1,"I 9,/% City ('. ) -/ J�rrTL�G�ta � V 1 Z113 Z`%UI
Office Phone: L) Cell # "IX # E -mall
APPLICANT INFOMMATION
Check Any that apply- Change of ownership Change of use Change of name New business
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BusinessName/Type: --46'F! 0 (7, 1 41 r '__�l�/�►'L��
Previous Business Business on this site iQe r13�` 1(
Describe the proposed business including use, number of employees, number of shifts, available parking spices, number of
vehicles, and any additional information that you can provide;
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*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' permission to use the space indicated on this application. I also certify that the information provided
is true and accurate to th 'best of my know dge. I have read the conditions of approval, and I understand them, and that I will abide by them.
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Signature �f' Printed
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APPROVAL INFO/ftNIATIO
X 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 (C ! t 3
Zoning Official f r Date L147-1-V2
Date
Other Official
E;ounty or Aloemarre ueparcnrum ul t,uuunuuicy afnrcfuNurcu�
401 McIntire Road Charlottesville, VA 22902 Voice, (434) 296 -5332 Fax: (434) 972.4126
Revised 7/1/2011 Page 2 of 3
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Intake to complete the following.
Reviewer to complete the folloiving:
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.
6 / N
Permitted as;
Nit re be food preparation?
Under Section:
If so, give applicant a Health Department form.
Zoning review can not be in until we receive approval from Health
Dept. FAX DATE
Supplementar/ regulations section:
Variance;
YIN
If so, List:
Circle the one that applie
Is parcel on privatew cnubl�te
Parking formula:
Required spaces:
If private well, provide Healt 'apartment form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Y/N
Circle the one that applies
Items to be verified in the field:
Is parcel on septic
SDP's
Y
W it ou be putting up a new sign of any kind? If so, obtain proper
Sign permit:
Permit #
Inspector:. Date;
I Y ,(�
Notes:
Will ere be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
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Violations:
Y/N
If so, List:
Proffers:
Y/(O
If so, List:
Variance;
YIN
If so, List:
SP's:
YIN
If so, List:
Clearances;
SDP's
Revised 711/2011 Page 3 of
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