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Application for Z011i g Clearance
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OFFICE USE ONLY ��••��
UK-z"O"'ing learance $35 f CLE # Z(D0 Ca
PLEASE REVZE LL 3 SHUTS Cheep # qqa' 'S Date: - z s - oco
Recei # / 2 2 Staff.,
PARCEL INFORMATION "io.�
Tax Map and Parcel: 4 — — 0-V — Existing Zoning
caner- ,ld! (o-�l Gt G-� Fill � W/Jfr 4 /Liec,i -f-rZ
FarcelO -
Oro -ri A4 t—w I) 411VD city ✓ ✓'4-
Parcel Address: Z;P
2 �9B�
(include suite or floor)__
PRI1Vt,A)WCONTAC'X'
Who should we call1write concerning this project?
Address: 11f 20 &OA'eGg 64t&4'6 City 400 4V 'CL-6- State M Zip Zo8 `y
Office Phone: (30(1 g �I. Cell # Fax #' 3�� g 8/ G � � -mai[ v vl/ Q! 's �� �' �e �aJ.
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PRO,T�CT INFORMA ON . --
Business Name/Type, , ,4 ✓/ V (�D12M'eft w ( A-M"y 41,54t,141 e-4"
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Previous Business on this site:
;Proposed use: /��D�l� (i��Q G �Gr!•(� G / �/!'?i o%!S
Circle'(if applicable): Fireworks / Christmas Tree
SEE CONDITIONS OF APPROVAL IF THE CLEARANCE 1S FOR FIREWORK OR CHRISTMAS TREE SALES (Sheet 1)
*This Clearance will only be valid on the parcel for which it is approved. If you cliangt, intensify or move the; use to a new location, a new Zoning
Clearance will be rcquirc4_
I hereby certify that I own or have the owners permission to use the space indicated on this application. I also certify that the information provided is
true and accur net? the best f ny knowledge. have read the conditions of approval, and I understand tbern, and that I will abide by them.
lSignature � Printed S%EP4116 � 1-r2i4'ak'`(
..... i ................. ......------- ......................................... .-------------------------- ...,, ...................
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AP�I'tOVAL INk'URMATION
14 Approved as proposed j ] Approved with conditions
![ ] Backflow device and/or current test data needed for this site. Contact ACSA 977 -4511, x119 -
�Qj No physical site inspection has been done for this clearance. Therefore, it is not-a-doteLMination of com fiance with the existing
site plan. $ackfloW Device and%oC
( I This site cbrnplies with the site plan as of this date. Carrent Test Data Needed
Building OfliCial Date. otO
Zoning Official ` Date B 6
Other Official Dale
rtr ......................... — ----------- --- . - - - - -- --- -..... - - -- .........''�a-._o- -' 7�z ....-------------- .......
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA, 22902 Voice'. (434) 296 -5832 Fax: (434) 972 -4126 10/14/05 Page 2 of 4
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Applicant to eomplete the fallowing:
0/ N
� o you have one of the fallowing?
Tax Map and Parcel Number and or;
Address of use (include unit or floor if appropriate;
0 `I7' N
o you have a Floor Plan (sketch or an architectural drawing) that
includes the following, and if so please provide it with the
application?
The total square footage of the use and /or;
The square footage of each room or area of use;
Use of each room or area
if using less than the entire structure, note the location within the
structure.
jY( >YYdd I U 115018tilb.(J'( r. 1 ,3/174
Intake to complete the following:
Is use in LT, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y y
Wilbllere 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
Y CN
Is parcel on private well and septic?
If so, give applicant a Health Department form.
Zoning review can not begin until we receive approval from
Health Dept. FAX DATE
N
Is on public water and sewer?
Y 49
Will you be putting up a new sign of any kind? if so, obtain
proper Sign permit,
Permit #
,
Qifthere be any new construction or renovations?
if so, obtain the pro er Permit. _ ---
Perth it# lull `
Y ' N
Is this for sales of Fireworks?
If so, obtain a copy of FIR permit.
Permit #
Zoning Tech to complete the follawa><a>�: S� / ��a- -- i� ► I I (S ! i"�Y
var e:
YIN
Ifs , ist.
Pro s:
Y/
If so, "st.
`1fst: q-P 9�_ & %
10/14/05 Page 3 of 4
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Reviewer to complete
Square footage of Use:
Y/N r
Permitted as:
Under Section:
Supplementary regulations section;
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'Parking formula:
Required speoes:
to he verified in the field: OWK
Inspector Name & Date:
I (Votes
r
MAR 2 8 2006
. , i _' 7-
10/14/05 Page 4 of 4
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