HomeMy WebLinkAboutCLE200800074 Legacy Document 2013-01-11Application for
Zoning Clearance
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❑ Zoning Clearance = $35
OFFICE USE ONLY
CLE # Q0696e,67
Check # Date: — 7 C3
Receipt # %6 Staff:
PLEASE REVIEW ALL 3 SHEETS
PARCEL INFORMATION
Tax Map and Parcel: LW Existing Zonin
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Parcel Owner:
95 ;Plv• �M� T
Parcel Address: I n06 ( r-44 ` City State Zi
(include suite or floor)
PRIMARY CONTACT
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Who should we call /write concerning this rojec n14—
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Address : City
Office Phone: Cell # �3 / 95�Fax #
APPLICANT INFORM�� ION
Business Name /Type: 1 IA-C d °Vw ► �Q V ��1�r`Q�w � `�" " `.'�-')
Previous Business on this site—
Describe the proposed business, including use, number of employees, number of shifts, available parking spaces and any
additional information that you caV provide•
*This Clearance will otily 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 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 acc ra to the best of ny k wI dge. I have read the conditions of approval, and I understand them, and that Iwill abide by them.
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Signature Printed
APPROVAL INFORMATION
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[ ] Approved as proposed [ �4pproved with conditions [
[ ] ,Bacl&ow prevention device and /or current test data needed for this site. Contact ACSA, 977 -4511, x1 19.
No physical site inspection has been done for this clearance. Therefore, it is not a determination of compli I e existing
site plan.
[ ] This�ite s wit11- 1e site pla� 4 of its date.
N tes:
Building Official Date 4 `e lag-
Zoning Official Date d z d 00
Other Official Date
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
511106 Page 2 of 3
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Intake to complete the following:
❑ YES [/NO
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
❑ YES DINO
Will there bcyfood preparation?
If so, give applicant a Health Department form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
❑ YES ❑ NO
Is parcel on private well or Qblic ter?
If private well, provide Heament form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
❑ YES ❑ NO
Is parcel on septic or p �So ?
❑ YES ❑ NO
Will you be pu r a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
❑ Y S
Will the y ne c lstruction or renovations?
If so, obtain t e prope rmit.
Permit #
Gomng i ecn to commete the tonowm2:
Violations:
❑ YES j! NO
If so, List:
Variance:
❑ YES NO
If so, List:
Reviewer to complete the following:
Square footage of U.--- /' P
❑ YES J ` ~
Permitted a,
Under Section: AP
Supplementary regal tions sectio3�
CIV
(p . oc
Parking forma a:
aZ
Required spaces-� _ Q
❑ YES ❑ NO
Items to be verified in the field:
Inspector : Date:
Notes: I&
Proffers:
❑ YES ® NO
If so, List:
SP's:
❑ YES 0'NU
If so, List:
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