HomeMy WebLinkAboutCLE200800200 Legacy Document 2013-03-18Application for Zoning Clearance
CLE # *2,0 7 -2,00
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OFFICE USE�QN Y
Date: 'Z jJ
Zoning Clearance = $35
PLEASkVIEW ALL 3 SHEETS
Check # C�
Receipt # Staff:
PARCEL INFORMATIDN
Map Parcel: ` 00 — or.) ' �i � �lv d Existing Zoning_��1�
Tax and
Parcel Owner: i C i i� , ' �� l ram Q 1'� 1" I-11 No re-
Parcel Address: 1 O0I YY� I �1� ,Q City IV rrfJ 3 i I I4�;State U Zip t0'`7
(include suite or floor)
PRIMARY CONTACT
Who should we call /write concerning this project? .
Address :121 V V yo/ u' f'` City — c ,Ct. � State i) ' `q
Office Phone: � 77t/ —6 Yr ' ell # Fax # E -mail
APPLICANT INFORMATION
Check any that apply: Change of ownership Change use Change of name New business
Business Name /Type:
\of
eiY 1� �
1
Previous Business on this site�`��2.t ._1l
Describe the proposed business including use, number of employees, umber, of shifts, available parking spaces, number of
v 'cles, and any additional information that you can provide:
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i- C V T*^ I' - �, (' o 4:Lv
*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 accura ie t of my knowledge. I have read the conditions of appro al, and I understand them, and that I will abide by them.
Signature Printed s
APPROVAL INFORMATION %
Approved as proposed [ ] Approved with conditions []'Denied
[ ] Backflow prevention device and /or current test data needed for this site. Contact ACSA, 977 -4511, x119.
[ ' ] 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 cot plies with the, site an as -
Notes: !//'�
Building Official Date
Zoning Official Date i l�s
Other Official Date
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
I.
Intake to complete the following:
Reviewer to complete the following:
Y �I,j
Square footage of Use:
Is use m LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y / N
Variance:
Y/N
If so, List:
Permitted as:
� Y J/ N
ill 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
Supplementary regulations section:
Dept. FAX DATE
SDP's
Circle the one that applies
Parking formula:
Is parcel on private well or 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
Circle the one that applies
Items to be verified in the field:
Is parcel on septic or public sewer?
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Inspector : Date:
Y /
Notes:
Wil be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
7nnina to rmmnlPtP the fnllnwinu'
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