HomeMy WebLinkAboutCLE201000242 Legacy Document 2012-04-11App'lication for Zoni's flearance
'CLE # V/a -- m
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r. Zou €ng Clearance = $35 Check # D ° Date: `�—
'LEASE REVIEW ALL 3 SEEETS Receipt # b`1 Staff: �
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Tax Map and Parcel: ) ~ ir1 b �� Existing Zoning ZL� P
Parcel Ohvner: i INMA461+
Parcel Address; _�- __(V_ -- State Z(p
(include suite or floor)
PRIMARY CONTACT `
Who should we call /write concerning this project? -1 \, Pry � �•
Address ; 2-7b� N% \k c, R ei h Akity 1 v ti L State V i ► Zip -� l6�
. x=13 �t '
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Offlce Pi►orhe: (� o t Cell # ){ax #
APPLICANT INFORMATION
Check any that apply: Change of otivnershlp Change of use Change of name New business
Bushhess Name/Type: tt ,
Previous Business on this site
Describe the proposed business Including use, number of employees, number of shifts, available pat:king spaces, number of
vehicles, and any additional Information that you can provide:
*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 penitission to use the space indicated on this application. I also certify that the infonnation provided
is true and accurate to tlhe best of my knowledge. I have read the conditions of approval, Al understand them, and that I will abide by tlieni.
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Signatur Q� �F Printed.
APPROVAL INFORMATION
Approved as proposed [ j Approved with conditions [ } Dethied
( j Backflow pf cvcntion device and/or current test data needed for this site, Contact ACSA, 977 -4511, x 117.
[ .) 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,
Dotes:
Bttildiitg Official Date I �6t
Zoning Official Date ,f
Other Officlal
X. ,
; t Date
County of Albemarle Depat•tmetht'of CommunttyDevelopment
401 McIntire Road Charlottesville; VA. 2290Z Voice: (434).296 -5832 Fax: (434) 972 -4126 -
Revised 04/28/08, 10 11.3 /09 Paget of
Intake to complete the followings Reviewer to complete the following: - - -- - - -
Y / Square footage of Use:
Is usein LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet. & N
-- - -- - - - - -. - -- -- - - -- — - - -- - - -- . -Rerrnitted.as:__.-
N
Mll there be food preparation? Under Section: 7- 7- -
-= If-so, give applicant -a- Health - Department -fon*n.
- -- - - "Zoning- review- can - not begin- until -w�eceive- approval fi•om- Health -- Supplementar -y- regulations section:------ -- - -- - - --
Dept. FAX DATE _�
Circle the one that applies Parking formula:
Is parcel on private well or`n_ Wic =W;1-
If private well, provide Health Department form.
Zoning review can not begin until we receive approval fi•om Health Required spaces:
Dept. FAX DATE
Circle the one that applies
Is parcel on septic or public sewer?
Y /Q
Will you be putting up a new sign of any ]rind? If so, obtain proper
Sign pen-nit.
Permit #
Y/N
Will there be any new construction or renovations?
If so,'obtain the proper Permit.
Permit #
Y/
Items to be verified in the field:
Inspector•
Notes:
Date:
Violations:
f so, List:
Proffers:
Y/
If so, List:
Vari,t ce:
Y /
If so, List:
SP's:
(�')/ N
so, List:
q J/
✓ )
�y
vu y/
Clearances:
0-7-20)
SDP's
Revised 04/28/08, 10/13/09 Page 3 of 3
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