HomeMy WebLinkAboutCLE201300154 Legacy Document 2013-08-13Application for Zoning Clearance
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OFFICE U ONL l `n ✓ ��
FJ Date: L
PLEASE REVIEW ALL 3 SHEETS
Check #
Staff:
Receipt #
PARCEL INFORMATION
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Tax Map and Parcel: GIE - 1 ^ Od - 5' Existing Zoning
Parcel Owner: Sot v%- �to epi-
Parcel Address: IS 'j'Z.. Sy�u7o��n;S CT . City ckecf l ilz- State Vft Zip-7Z111 1.
(include suite or floor)
PRIMARY CONTACT
lj
Who should we call /write concerning this project? keilL- ar' Q�
Address : t-10 S, Qc`^ 'S Dr' � City chA rld1�-ei to State VA Zip'z2EI11
Office Phone: 1{( 3Ll) 2�iS-�'bgL( Cell # 9G Z S LI R Fax # ZuS -a$9 S E- mail
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name /Type: ihsjk
Previous Business on this site
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 - Printed glue Cam, Eek
APPROVAL INFORMATION
>Q 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 - Date
Other Official Date
County of Albemarle Department of Community Leve1opme11L
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
Revised 7/1/2011 Page 2 of 3
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In a to complete the following:
Y N
Is u i LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y/N
Wil e be food preparation?
If so, give applicant a Health Department form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applies
Is parcel on private wel r public wate .
If private well, provide / e D ent form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that Olies Is parcel on septi o ?
Y N
Wi yo e putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
N
W ll there be any new construction or renovations?
I so, obtain the prop r ermit.
Permit #
Zonin to com lete the following:
Reviewer to complete the following:
Square footage of Use:
(r /N
Permitted as: D e,
Under Section:
Supplementary regulations section:
Parking formula:
Required spaces:
.1
Y/N
Items to be verified in the field:
Inspector : Date:
Notes:
Violations:
Y / -IV
If so,—List:
Proffers:
Y /
If so, List:
Variance:
Y / �IsI�
If so,Zist:
SP's:
Y/
If , List:
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3
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