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Application for Zoning Clearance
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CLE # 1,P
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Zoning Clearance = $35
PLEA
OFFICE USE ONLY
Check # 825 0 Date:
Receipt # NCO t_ Staff: !
VIEW ALL 3 SHEETS
PARCEL INFORMATION
Tax Map and Parcel: -e' o 6 i Existing Zoning
Parcel Owner: hm,1V r '
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0, State Zip Z
Parcel Address: `,Cit t4<"J0 ,�WJ 11e 2l0
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(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project? vl�9v�°.a2zi6� :al t
Address : 7 6 �C�/1✓Od,/� �/on/ l/►� City "' /L% -�J�i ��State Zip
Office Phone: &, / Cell # Fax # ��id�0 E- mailhrli9n�A�'J r
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
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Business Name/Ty e: 7 �c�t> Z)V �D/✓l7 ,/10 �r
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Previous Business on this site Altw ' ��rg2•<i?r'%
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Describe the proposed business including use, number .of employees, �n tuber of shifts, available arking spacest number of
vg 'cles, and any additional information that you ca rov/ide: �?� ��EpS�' as C� t C
Apt e- A3 r S flr i xiS ° j3cnrc i�t d• 6U .90 rya 't'1-4 CcvKf'
C_ inl'In v IS `C' 44 id,PrAC`.e ii4 ' ;1v Ky s- WV J i�'Ra 0V JS.
*This Clearance wilf only be valid on the parcel for w ich it A approved. If you change, intensify or radve the use to a new location, Mew Zoning
Clearance will be required.
1 hereby certify that I n or have the owner's permission to use the space indicated on this application. I also certify that the information provided
is true and aecurate't a best of owledge. I have read the conditions of approval, and 1 and stand them, and that 1 willabideby them.
Signat%re Printed
APP VAL INFORMATION
[ pproved as proposed [ ]Approved with conditions [ ]Denied
[ ] Bacicflow 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
ite plan.
[ ] This site complies with the site plan as of this date.
Notes:
Building Official Date v�
Zoning Official Date
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
-20
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Intake to complete the following: Reviewer to complete the following:
Y / N Square footage of Use: O
Is use LI, HI or PDIP zoning? If so, give applicant a Certified r
Engineer's Report (CER) packet.
- .ermitted
Willo e be food re aration? Under Section:
P P
If so, give applicant a Health Department form.
Zoning review can not begin until we receive approval from Health Supplementary regulation section:
Dept. FAX DATE
Circle the one that applies Parking formul
Is parcel on private well public water�}
If private well, provide IIealt epartmlnt 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 o
Y/N `.
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit # Inspecor : t Date:
Y / N Notes:
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning, to comnlete the following:
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Y(/
If =so, i t:
offers:
/ N
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Vari e:
Y / rN
If sol Isi
SP
Y
I so, List:
7
Clearances:
SDP's
Revised 04/28/08 Page 3 of 3