HomeMy WebLinkAboutCLE201200099 Legacy Document 2012-05-23�•J
Application for Zoning Clearance
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CLE # 2012 OR
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PLEASE REVIEW ALL 3 SHEETS
OFFICE USE ONLY
Check# Date:
Receipt # Staff: ��—
PARCEL INFO
PD
Tax Map and Parcel: M Existing Zoning fft 0-
Parcel Owner:
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Parcel Address: `{'.� /' � 1- Ci State t-i • Zip
(include smte or t7oor) •
PRIMARY CONTACT
}Vho should we cal] /write concerning this project? :ZIAA( A-64 1EXT
pp I Fo mar < VA Zi S W
Address : I S t� b � '/ Fr R� City �% State
/p�'.'
Office Phone: Cell # -qT y 5,25 75-tYax # E -mail I�R i�° �T �(s7/�.tt/ L• C
(!�` '--% A
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
y
Business Name /Type: 'UDO %Roz a/ Ve C ItE
/> A
A
Previous Business on this site`
Describe the proposed business including use, number of employees, number of shifts, available parking spaces, number of
vel icles, and any additional information that you can provide:r:��- SEi2V�C : :y�Z7
54t!✓7S 2 gEK. �j�! PAPY -4 9 NpAo PAS 6 -6 yiy+1ef>is
" *This Clearance will only be valid on the parcel for which it is approved. If you change, intensify or move the use to anew location, a new Zoning
Clearance will be required.
I hereby certify that I own or have the owner's pernussion to use the space indicated on this application. I also certify that the information provided
is true and accurat o the best of my laiowledge. I have read the conditions of approval, and I understand them, and that 1 will abide by them.
Signatur �—� Printed �j• 1,4(0/ •, �%i 1rE �'
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 t
Zoning Official Date ZD ��
Oilier OfflcinC `• Date
County otAlbemarle JJepartment 01 uominumry Leveropmeni
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
Revised 1/1/2011 Page 2 of 3
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intake to complete the following:
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Is use ni LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y ,t N 1
Will eie be food preparation?
If so, give applicant a Health Department form.
Zoning review can not begin until we receive approval fi•om Health
Dept, FAX DATE
Circle the one that applies
Is parcel oil private well i
blic wa .
if private well, provide Hea �epartment form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applies
Is parcel on septic ublic y�
YIN
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
YIN
ill there be any new construction or renovations?
If so, ob 1 , ope Permit # �
Reviewer to complete the following:
Square footage of Use:
&/N
Permitted as:
Under Section: -�
Supplementary regulations section:
Parking formula: 0
Re uii•ed spaces:
Y/
Items to be verified in the field:
Inspector : Date:
Notes:
Violations: _
Y0
If so, List:
offers:
Y/N
If so, List:
Vari. e:
Y/N
Ifs , ist:
SP's:
�/N
so, List:
d,S Z.
rl ✓�' J
— Clearances:
SDP's
Revised 1/1/2011 Page 3 of 3
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