HomeMy WebLinkAboutCLE201200044 Legacy Document 2012-03-09Application for Zoning Clearances_
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CLE #
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OFFICE US NLY
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PLEASE REVIEW ALL 3 SHEETS
Check # Date:
Receipt # Staff: r
PARCEL INFO/� }\\
Map and PaV� ^'1' n I ` Existing Zoning
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Parcel Owner: 1, 1
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Parcel Address: .— City ip State i'1 Zip,
(includeAte or floor)
PRIMARY CONTACT iy
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Who should we call/write concerning this project? � T_
Address: 3z� R"P CityatAr kP �k State Zip 2--Z
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Office Phone: ax # - E -mail �+
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APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
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Business Name /Type: I ,/
Previous Business on this site
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: 6 r*- ,,,c,,r- _n�o 7 ,fgi
*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 knowled ditions of approval, and I understand them, and that I will abide by therm.
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Signature Printed
PROVAL INFORMATION
[Approved as proposed [ ] Approved with conditions [ ] Denied
[ j 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 detenninafion 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 llepartment of uommumty veveiopmenr
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
Revised 7/1/2011 Page 2 of 3
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Intake to complete the following:
Is/
Is u e in LI, HI or PDIP zoiung?
Engineer's Report (CER) packet.
If so, give applicant a Certified
Y/O
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
Circle the one that applies
Is parcel on private well or lic wate
If private well, provide Health Department form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applies
Is parcel on septic or public sewer
Y
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y /�
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
7nnina to rmmnlefe flee fallnwin4:
Reviewer to complete the following:
Square footage of Use: 60
O/N
Permitted as:
Under Section:
Supplementary regulations section:
Parking formula:
Required spaces: /
Y
Items to be verified in the field:
Inspector : Date:
Notes:
Violations:
(
If so—,List:
Proffers:
Y /KI
If so" fist:
Variance:
Y /�N>
If so``1 ist:
SP's:
Q/N
If so, List:
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Clearances:
SDP's
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Revised 7/1/2011 Page 3.of 3
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