HomeMy WebLinkAboutCLE201300148 Legacy Document 2013-07-29Clearance
Application for Z? o Clearance
CLE #
OFFICE USE O Y
I
PLEASE REVIEW ALL 3 SHEETS
Check # ate:
Receipt # Staff: J
PARCEL INFORMATION'n
-" D S Existing Zoning 4 (0 PM.�c�l�le
Tax Map and Parcel: 0 6 0vA Q' Q Q --12 ON
Parcel Owner: 1) "'\ M Ot i A Q
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r n
Parcel Address: 6 0 �Q r% m 4c Cj f cte City (61,10 ((II� es y,, I)e State VA Zip 2Z 9 D]
(include suite or floor)
PRIMARY CONTACT / JJ
C r15 PGS G h
Who should we call /write concerning this project?
Address: in $ , �t A q s M OwJ11 a ✓+ m. City chur !a ties vi ,lle State VA Zip
Office Phone: Cell # 11.1-1310 Fax # E -mail do (j W40 Jars. com
APPLICANT INFORMATION
Check any that apply: V Change of ownership Change of use Change of name New business
llw -•�
Business Name /Type: akoo 1,- 1 s, LL C
Previous Business on this site k vt ✓� � n j&A L eRf yI r 4 l e of 2%
Describe the proposed business including use, number of employeest number of shifts, available parking spaces,,1 number of
ErjnN i LQ� � ft Cryn IwP+'1
vehicles, and any additional information that you can provide: TM rtw aAJ Y�a rG � 1 7
*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.
l,/�°Il�
Signature (% %�< .�^— Printed (,f � f � e r pas (A'711
APPROVAL INFORMATION
kQ Approved as proposed [ ] Approved with conditions [ ] Denied
[ ] Backflow prevention device and /or current test data needed for this site. Contact ACSA, 977 -4511, x117.
[ ] 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 complies with the site plan as of this date.
Notes:
Building Official Date
Zoning Official z Date
Other Official Date
County of Albemarle impartment of Uommumiy VevewlnucuL
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
Revised 7/1/2011 Page 2 of 3
Intake to complete the following: Reviewer to complete the following:
Y / N Square footage of Use: �� 20
Is u n LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet. 61 N
Permitted as: proL ce_
Y
Wil ere be food preparation? Under Section: -;7- J A• 2
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
Circle the one that applies
Is parcel on private well o public water?
If private well, provide Hea H�prarhr� orm.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applies
Is parcel on septic o public sewer?
4 Y/N
ill you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit # �nn
Y q N/
Wil ere be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zonin to com lete the followin :
Parking formula:
Required spaces:
Y/N
Items to be verified in the field:
Inspector : Date:
Notes:
Violations:
Y / [�T/
If so, List:
Proff r s:
Y/'
Ifs , st:
Varia• ce:
Y /1
If so, List:
SP's:
Y/Ni)
If so, ist:
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3
CERTIFICATION THAT NOTICE OF THE
APPLICATION HAS BEEN PROVIDED TO THE LANDOWNER
This form must accompany zoning applications (Home Occupation, Zoning Clearance, Zoning
Administrator Determinations or Appeals, Sign Permits, Building Permits) if the application is not the
owner.
I certify that notice of the application,
[County application name and number]
was provided to )6h. M G" A p, the owner of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number 0 0 - I Z Q S by delivering a copy of the application in the
manner identified below:
Hand delivering a copy of the application to �o by i� ��� e
[Name of the record owner if the record owner is a
person; if the owner of record is an entity, identify the recipient of the record and the recipient's
title or office for that entity]
Date
Mailing a copy of the application to
[Name of the record owner if the record owner is a person;
if the owner of record is an entity, identify the recipient of the record and the recipient's title or
office for that entity]
on to the following address:
Date
[address; written notice mailed to the owner at the last known address of the owner as shown on
the current real estate tax assessment books or current real estate tax assessment records satisfies
this requirement].
SignJ/ature/ of Applicant
�Yldl }T /ihP/` ��$t�ti�I
Print pAt p atcl nt Name
i- g -zon
Date
t,
E&�H O O TORS
Emergency Evacuation Plan
Directions: Complete and post this form by every telephone in the Center. Section 1 lists local emergency phone
numbers. Section 2 presents a floor plan of the Center, indicating the location of emergency exit signs and the
evacuation destination unless it is inaccessible. In that case, use the secondary evacuation destination.
Section 1: Emergency Phone Numbers
Emergency: 911
Fire:
Police: 911.
Hospital: 911
Section 2: Evacuation Route
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Section 3: Evacuation Destinations
PRIMARY:
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SECONDARY: Rear Parkivu Lott'
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