HomeMy WebLinkAboutCLE200800122 Legacy Document 2013-01-17Parcel Address
(include suite or floor)
City
State
Zip
PRIMARY CONTACT
Who should we call /write concerning this project?
Address : 1 City NQ-lk State Zip
Office Phone: Cell # Fax # E -mail
I APPLICANT INFORMATION I
1
Business Name/Type:
Previous Business on this
Describe the proposed business including use, number of employees, number of shifts, 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 / ii �22.�_ i— -� Printed l �c� �"� /�. 41- /,/'/.rte-. ;zzz�
ica isi tenspection has
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
Intake to complete the following:
Y /(. )
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Reviewer to complete the following:
Square footage of Use:
Y/N
Permitted as:
Y/N
ill there be food preparation? Under Section:
If so, give applicant a Health Department form.
Zoning review can noj be in u t we receive approval from Health Supplementary regulations section:
Dept. FAX DATE
Circle the one th es Parking formula:
Is parcel rivate wdQr public water?
If private well, provide Health Department form.
Zoning review can not begin until we receive approval from Health Required spaces:
Dept. FAX DATE
Y/N
Items to be verified in the field:
Circle the one that applies
Is parcel o septic public sewer?
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit # Inspector : Date:
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/N
If so, List:
Variance:
Y/N
If so, List:
SP's:
Y/N
If so, List:
Clearances:
SDP's
Revised 04/28/08 Page 3 of 3