HomeMy WebLinkAboutCLE200600201 Legacy Document 2014-10-03,5r,
Application for
Zoning Clearance
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Clearance =
OFFICE USE ONLY
O °' 20
ning $35
CLE #
PLEASE REVIEW ALL 3 SHEETS
Check # 130 0 S Date: T- 1 ` -- 0
Receipt # & 1,95 3 (p Staff:
PARCEL INFORMATION
Tax Map and Parcel: -7 8 / / -zo AA Existing Zoning _ I - ✓�
Parcel Owner:_ �/ Y A V� U LI 7A T o% l 4- Rio n EE LL LA�72 f C Af rM E Co .
W O U-15 �-- City CW A- FZt6TJ U�V 1 tate VA- zip
Parcel Address: OD DV--
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project? CYO pV(l
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Address: qO 0 W O (e.le 0D-L 2 -9- City C�{`A''12-�, T5V1�tate V ff- Zip2Z9
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Office Phone: (l) 2-t `O Z3 Cell # q (QO _ Zg22Fax # 2,4q-02-35 E -mail ��[ / /L G �C�i V i ✓'q) ✓11 �C
APPLICANT INFORMATION
Business Name/Type: K I u G P- ex4 jti.2 kfo b r -eea Li cL I A-r-E u i' n/t 6 Lkfie U04 �A VA
Previous Business on this site O rrC fic c ✓J r1; .; i!!�S
Describe the proposed business, including use, number of employees, number of shifts, available parking spaces and any
add'tional information that you can provide: O u +cl ,nn C n[5Y1 Ce r i- o n- S erg ( Z`3 , 2D6(p
VCa Yr W Lo��2 nf) ofCL I:te %,042+ Z y 26 0
*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 II understand them, and that/ I�will abide by them.
Signature G-, Printed r V l a r` c16 �►'Vt i �L,
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, x119.
[ ] 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 �v.�� Date
Zoning Official Date
Other Official Date
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 4126
511106 Page 2 of 3
1
Intake to complete plete the following:
F] YES 101 pl
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
❑ YES t NO
Will 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
❑ YES U/N"O
Is parcel on private well or public water?
If private well, provide Health Department form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
"S ❑ NO
Is parcel on septic or public se er?
❑ YES [;J NO
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
❑ YES NO
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Coning 'l'ech to complete the following:
Violations:
❑ YES ❑ NO
If so, List:
Variance:
❑ YES ❑ NO
If so, List:
Reviewer to complete the following:
Square footage of Use: _� .(a (;1 b t j - ` a re
YES ❑ NO
Permitted as: Q,,�,1,
Under Section: /"' "i' /"
Supplementary regulations sectio :
16 pl—
Parking formula: 5;&
Required spaces:
❑ YES ❑ NO
Items to be verified in the field:
Inspector : Date:
Notes:
Proffers:
❑ YES ❑ NO
If so, List:
SP's:
❑YES El NO
If so, List:
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