HomeMy WebLinkAboutCLE200800172 Legacy Document 2013-02-19PRIMARY CONTACT A
Who should we call /write' ^c'onncerning this project? � "� 51�
Address : ��� i�� ro^g City AI State VIA— Zip-OL
Office Phone: U� ell # Jq6-1gQ2 Fax # E -mail M"
APPLICANT INFORMATION I
Business Name /Type:
Previous Business on this site
Describe the proposed business including use, number of employees, number pf shifts, av tl le par" g spaces, number of
vehicles, and any additional inforrDation that yQu can provide: �IillU�— (� � h2kN7
*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 r have the owner's percussion to use the space indicated on this application. I also certify that the information provided
is true and accurate t re b of nowledge. I have read the conditions of approval, and II understand them, and that I`� will — abide. by them.
Signature Printed 0``��`^-s bp4aye
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
4`72_ G -2�
Intake to complete the following:
Reviewer to complete the following:
YO
Square footage of Use:
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y / N
Permitted as:
/N
SP's:
Y/N
If so, List:
Will there be food preparation?
Under Section:
If so, give applicant a Health Department form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE /'
Supplementary regulations section:
Circle the one that applies
Parking formula:
Is parcel on private well or p lic wa er.
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
Circle the one that applies ��
Items to be verified in the field:
Is parcel on septic or ublic sewer i
Y/N
Will you be putting up a new sign of any Icind? If so, obtain proper
Sign permit.
Permit #
Inspector : Date:
e9 / N
Notes:
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit # /I— o / ,d C,
7nninu to emmrilPtP the fnllnwinoF:
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