HomeMy WebLinkAboutCLE201400182 Legacy Document 2014-09-18Application f ®r Z®niff Clearance
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CLE # 14 •)
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PLEASE REVIEW ALL 3 SHEETS
OFFICE USE ONLY I
Check # 1 x� Date:
Receipt # Staff: VYWD
PARCEL INFORMAT ON p
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Tax Map and Parcel:, Existing Zoning /��
Parcel Owner: dte ltd
Parcel Address: ,,o{ /.S � City Llr--6Gk�110%.tate 0.— Zip 2Z u
(include suite or floor)
PRIMARY CONTACT
Who should we call /write concerning this project ?
Address : Pa 573 City, /!Aar /offesuli_1 ,State 1"4 Zip Zz'?O
Office Phone: (±3b Cell #011 9SJko f Fax # f;V E -mail
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name /Type: 07c7 r��� lLCott�t SSc�G. CaF �P2V4�A C3 X111 9/z Izaf�
Previous Business on this site y to
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: A�-5e &_C_ .,
o
*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 them, and that I will abide by them.
/unddeerstand
Signature Printed
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
Zoning Official ✓ Date
Other Official Date
County of Albemarle Department of uommumty iieveiopment
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
Revised 7/1/2011 Page 2 of 3
C-:1J', an—
Intake to complete the following: I Reviewer to complete the following:
Y / 6
Square footage of Use:
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Oe l NeQ
rmitted as: I
�Y /N
Will there be food preparation?
Under Section: .-!� ,P
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 a s
Parking formula:
Is parcel on rvate or public water?
Realth
If private well, prove Department form.
Zoning review can not begin until we receive approval from Health
Required spaces:
Dept. FAX DATE
Y/N
Circle the one that applies
Items to be verified in the field:
Is parcel on epti r public sewer?
Y /�
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Inspector : Date:
Permit #
Y / *
Notes:
Wil there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
7nninu to complete the following:
Violations:
Y /OI
If so, List:
Proffers:
Y /(N)
If so, List:
Variance:
YD /N
If so, List: q
SP's:
&IN
If so, List:
'7� 9
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3