HomeMy WebLinkAboutCLE201200079 Legacy Document 2012-04-30onin Clearance
Application fo2e
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OFFICE USE O Y fib- Z
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PLEASE REVIEW ALL 3 SHEETS
Check# Date:
Receipt # Staff:
PARCEL INFORMATION � - i �7 _H
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Tax Map and Parcel: Existing Zoning
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Parcel Owner: 1 _eyi n Sm t "1 t 1
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State 1 Zip
Parcel Address: city
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(include suite or floor)
PRIMARY CONTACT Inno s m �� o SI;
AWho should we call /write concerning this project? /s (,, �y -
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,ress: ) x z 1 City C / f ��i YI D es State V/- Zip
Jas )v-ev .en d VOTE—
Office Phone: (t E) Cell # Fax # E -mail �Unhrz Stml bl� V lVlCif ��C
APPLICANT INFORMATION
Check any that apply: Change of ownershipChange of use Change of name New business
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Business Name /Type: ,�R 1 I l� l 1
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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 Von can provide: q ErAn Ibi i y,5 2. CtV k
*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 c that I o or have the owner's permission to use the space indicated on this application. I also certify that the information provided
is true d accurate to the est of my dge. I hav read the conditions of approval, anndj I understand them, and that I will abide by them.
Signature - Printed I I o,
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APPROVAL INFORMATION
] Approved as proposed [ ] Approved with conditions [ ] Denied
[ ] Baclflow prevention device and/or current test data needed for this site. Contact ACSA, 9774511, xl 17.
[ ] 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 o 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
Revised 7/1/2011 Page 2 of 3
Intake to complete the following:
Y/N
Is use in LI, HI or PDIP zoiung? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y/N
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-b ublic w ter?
If private well, provide He lth D rtment form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applies
Is parcel on septic o publics er?
Y/N
Will you be putting up a new sign of any kind?
Sign permit.
Permit #
If so, obtain proper
Y/N
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
7nnina to complete. the fallowin¢:
Reviewer to complete the following:
Square footage of Use:
/N
ermitted as: 4; 4j n,e ems_O t n
L "e
Under Section: �s
Supplementary regulations section:
Parking formula: /
Requ' d spaces:
Y/
Items o be verified in the field:
Inspector:
Notes:
Date:
Viol ons:
Y/( ly
If so, List:
roffers:
/N
If so, List:
Variance:
Y /I�
If so, List:
SP's:
Y/Pist:
If so,
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3
CERTIFICATION THAT NOTICE OF THE
APPLICATION HAS BEEN PROVIDED TO THE LANDOWNER
This form must accompany zoning applications (Home Occupation, Zoning Clearance, Zoning
Administrator Determinations or Appeals, Sign Permits, Building Permits) if the application is not the
owner.
I certify that notice of the application,
was provided to
[County application name and number]
[name(s) of the record owners of the parcel]
and Parce umber
manne identified below:
Hand delivering a copy of the application to
the owner of record of Tax Map
by delivering a copy of the application in the
[Name of the record owner if the record owner is a
person; if the owner of record is an entity, identify the recipient of the record and the recipient's
title or office for that entity]
on
Date
Mailing a copy of the application to
[Name of the record owner if the record owner is a person;
if the owner of record is an entity, identify the recipient of the record and the recipient's title or
office for that entity]
on
Date
to the following address:
[address; written notice mailed to the owner at the last known address of the owner as shown on
the current real estate tax assessment books or current real estate tax assessment records satisfies
this requirement].
Signature f Applicant
Rbann.
Print Applicant ame
ID I
Date
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