HomeMy WebLinkAboutCLE201300209 Legacy Document 2013-11-08Application fo Zonin Clearance
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OFFICE US ON
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PLEASE REVIEW ALL 3 SHEETS
Check #
#
Date:
Staff:
Receipt
PARCEL INFORMATI N ��jj //��
Z`'1 -A Existing Zoning
Tax Map and Parcel: U1 _
Parcel Owner:
2g C -h�i lL(V
Parcel Address: , city �Y 1 V Y' � State y � Zi p ZLU
(include suite or floor)
PRIMARY CONTACT
Who should we call /write concerning this project ? /VAS €E M y
Address: _�a g A►d�r �� City c-1 ye f L State V A Zip � o
Office Phone: &W 17?-4337 Cell # 1� _ 44 825 S(I c Fax # E -mail ,i� �2C5 +4�3 FjOe• '
APPLICANT INFORM TION
Check any that apply: Id Change of ownership Change of use Change of name New business
Business Name /Type:
Previous Business on this site 14 r 1L . L P c; y eg
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: _ c N E .Ak(2_ K (\21< ,�4 L�
*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 A Printed u <�
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, 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 `t
Zoning Official Date ?Z_7 6 ?
Other Official (ybq 6 Date
UoUnty 01 AiDemarie iiepar6menL v1 %.ouuuuuny LUVc VFAALa..o
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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Intake to complete the following:
Y /
Is us LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
N
ill there 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 well r public water?
If private well, provide Hea t form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that a
Is parcel on septic o pplies lic sewer?
Y /0
Will you be putting up a new sign of any kind?
Sign permit.
Permit #
If so, obtain proper
Y N�
Will re be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Z ' to com late the followin
U11 1
Reviewer to complete the following:
Square footage of Use: •; Ofd 6
(_I / N /
Permitted as: �Jdi — C-1ye.
Under Section: Lei
Supplementary regulations section:
Parking formula:
Required spaces:
Y/N
Items to be verified in the field:
Inspector
Date:
Notes: j
t� L,
f
oin
Violations:
Y /No
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 7/1/2011 Page 3 of 3
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