HomeMy WebLinkAboutCLE201500034 Legacy Document 2015-03-06a Application for Zoning Clearance
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Ul FRX USE UNLY
]PLEASE IZE'VIEW ALL 3 SHEETS Check # Z S� Date: 1S'
Receipt # °1 Staff:
PARCIIL INFORMATION
7%— — Existing Zoning�c�ya
Tax Map and Parcel:
Parcel Owner:
Parcel Address: � '�'�itY ffiLamg il, we— WAC Zip, Uj
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project?e
Address : I S 00 �����LAct"' - City � dZl [?(-(�—`��%State \/A Zip
Cell # qeq Fax # E-mail
Office Phone: x.43
-
APPLICANT INFORMATION
Check any that apply'.._ Change of ownership C ange of use _Change of name w business
Business Name/Type: C ���Z--� I �"'�'
Previous Business on this site
Describe the proposed business including use, number of employees, number of shifts, available parking spam, nu ber o
s, and any additional information that you can provide: W i
'This Clearance vriq only be valid on the parcel for ich itis roved. Ifyeu change, intensify ar movethe use to a new locations anev+r 2aning.
Clearance will be required.
I Itereby certify that or have the own espe to s e space indicated on this application. I also certify that the information provided
is true and ecu best of my kno 4e. I have r the co ditions of approval, and I understand them, and that I will abide by them.
Printed�fa
Signature
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APPROVAL INFORMATION
Approved as proposed [ } Approved with conditions C ) 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
Date
Zoning Official
Other Official Date
County of AM= rle uepartmeua od 1-munRumLy wv wil uta,,..
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (434) 972-4126
Revised 7/1/2011 Page 2 of 3
X
Intake to complete the following:
Y O
Is use in LI, HI orPDIP zoning?
Engineer's Report (CER) packet,
If so, give applicant a Certified
Y
Wil sere be food preparation?
IV— ive applicant a Health Department form.
Reviewer to complete the following:
Square footage ofUse:t` }'—=--r
N
Krtted as' � 1
ermi
Under Section:?
)g
Zoning review can not begin until we receive approval from Health Supplementary regulations section:
Dept. FAX DATE
Circle the one that applieiotuebliew
Is parcel on private well ?
If private well.provide.H t forin.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applies
Is parcel on septic or is sewer?
Wii u be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
YN
Wi be any new construction or.renovations?
If so, obtain the proper Permit.
Permit #
17-....... fn fish frillAwin 8
Parking formula: y iS
Required spaces:
YIN
Items to bq verified in the field:
Inspector: Date:
Notes:
Violations:
IN
If so, List: n
roffers:
&IN
If so, List:
Variance:
YIN
If so, List:
IN
If so, List: 2 r�
Clearances:
SDP's
a
Revised 7/7/2011 Page 3 of 3
Exhibit A
Exhibit A-1
The Premises
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