HomeMy WebLinkAboutCLE201300216 Legacy Document 2013-09-26• •
Application for _Z T—� ng Clearance
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CLE #
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OFFICE U
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PLEASE REVIEW ALL 3 SHEETS
Check #
Date:
Receipt #
Staff:
PARCEL INFO f� /y 10
Tax Map and reel: (yryrUUA�1�. Ri'li(� Existing Zoning I
Parcel Owner:
Parcel Address: City Ji State VA Zip
(include suite or floor)
PRIMARY CONTACT n P
dl
Who should we call /wri oncerning this projec ?
Address 33—� K-NN4�a i V . Late zip
Office Phone: Cell # Fax # E -niai I •�Ji A P-i r l
APPLICANT INFORMATION
Check any that apply: a g of ownership _Change of use Change of name New business
Business Name /Type: l /
Previous Business on this site
Describe the proposed business including se, number of employe u ber of shifts, avail le 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 provi ed
is true and ac rate to the best of my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
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Signature Printed I
APPRO AL INFORMATION
e[�C] 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 �✓� r J Date /e3
Other Official Date
County of Albemarle liepartment of k.ommumty LevelVlnueuL
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
Revised 7/1/2011 Page 2 of 3
Z-o)
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Intake to complete the following:
Y /@
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Reviewer to complete the following:
Square footage of Use: I 1 1, SOD
() /N
Permitted as: q�e�Irz 4 ".., �1l
J�
� / N �� 2 . /
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
Circle the one that applies Parking formula: r `�
Is parcel on private well or blic Ovate �1�'�✓eN �n�a�i1U
If private well, provide Health nt form.
Zoning review can not begin until we receive approval from Health Required spaces: 2�
Dept, FAX DATE
Circle the one that applies
Is parcel on septic or ublic sewer
Y/N
Will you be putting up a new sign of any kind?
Sign per
Permit # t
Y/
Items to be verified in the field:
If so, obtain proper
Inspector : Date:
Y / N Notes:
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
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Viola ions:
Y
If so, List:
Proffers:
If so, List:
j_ J
Varia ce:S's:
Y
If so`List:
l' / N
If so, List:
Clearances: ?
SDP's
a
Revised 7/1/2011 Page 3 of 3