HomeMy WebLinkAboutCLE200800112 Legacy Document 2013-01-16Application for ZoninLy Clearance =�� °e�t�m
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CLE # age , 9 601
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PARCEL INFORMATION �l
Tax Map and Parcel: 03;ok06 —66 —'-"0 �- 6-:3 b/0 Existing
Parcel Owner: '✓in Q _, -A -.1) Q,'7- 0 (a 20. � L C_
Parcel Address
J s vu',"4 1 P�r `J City C1i + ,i 1 < State U A'
(include suite or floor)
Zip 2 2� 1I
PRIMARY CONTACT �� e
Who should we call /write concerning this project? V '�
Address : 0 City State Zip
Office Phone: �'( )� -1 g 1 1 Cell # C 1"k— Fax # E -mail
APPLICANT INFORMATION / I
Business Name /Type: /_ q) ® V r &t p -) \JA K r) . Utz Div, QA r e c Ii
Previous Business on this site
Describe the proposed business including use, number of
*This Clearance will only be valid on the parcel for which it is approved. if you change, intensity or move the use to a new location, a new Gonmg
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 d best of owledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
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Signature ''v Printed "� P��'
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 Page 2 of 3
(Y
Intake to complete the following:
Y/
Is us LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y /
t Will re be food preparation?
If so, 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 p ►c ter?
If private well, provide Health epa ent form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that appl'
Is parcel on septic or blic se r?
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y/N
Will there be any ew construction or renovations?
If so, obtain the pr per Permit.
Permit #
Zoning to complete the following:
Reviewer to complete the following:
Square footage of Use: �� U
Wrm `
itted as: Al
Under Section:
Supplementar regulations section:
Parking form i
Required spaces:
Y/N
Items to be verified in the field:
i lations:
, List:
V oN
Proffe s
Y/ U
If so, st:
Variance:
Y/
If so, ist:
SP's:
Y/N
If so 'st:
vt¢ b
41 LV41
Revised 04/28/08 Page 3 of 3