HomeMy WebLinkAboutCLE201500013 Legacy Document 2015-01-21Application foy Zoning Clearance��,:_'`
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PLEASE REVIEW ALL 3 SHEETS
Check # Date:
Receipt # Staff: myx%
PARCEL INFORMATI, i�} CA
` \ v A V 1b Existing Zoning
Map and Parcel: L4, 1
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ParcelOwner: �loll�/ y �� t� ,�C�"�`
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Parcel Address: '-1{'►`, U � �)l 766 IL,I ► City i \ �' State �1 A'i p
(include suite, or floor)
PRIMARY CONTACT��������_ l
Who should we call/write concerning this project?
Address: City G(v-0A StateZip
Office Phone: j_3 c Cell # 7Y'rE-mail mid%
APPLICANT INFORMATION-
-Check any that apply: Change of ownership Change of use Change of name New business
Business Name/Type:
Previous Business on this site
Describe the proposed business including use, number of employees, number of shifts, available parking spaces, number of
vehicles, and an additional information that you can rovide:
*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 o n or have the owner's permission to use the space indicated on this application. I also certify that the information provided
to best of my knowwl e. e read the c ditions of approval, and I understand them, and that II will abide byy them.
is true and accur to a
Signature
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
13
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County of Albemarle Department of Community Development -- - -- ---- --
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (434) 972-4126
Revised 7/1/2011 Page 2 of.3
Intake to complete the following:
Y / ..
Is us`e 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:b�
@ / N r
Permitted as: 6-Rcx�, iASe/
Y/
Will ere 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
Is parcel on private well or/p4 ►c wa er?
If private well, provide Hehltb-Dep, ment form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applE
Parking formula: fi—e4,
Required spaces: ✓y
Y/N
Items to be verified in the field:
Is parcel on septic o pr?
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Inspector : Date:
Y/N
Will there be any new construction or renovations?
Notes:
If so, obtain the proper Permit.
Permit #
Zonine to complete the following:
Violations:
j
If so;--Iist:
Proffers:
Y / O
If so, List:
Variance:
Y/
If so, List:
SP's:
Y/v
If so, List:
Clearances: SDP's
Revised 7/1/2011 Page 3 of