HomeMy WebLinkAboutCLE201200090 Legacy Document 2012-05-30t;
Application for Zoning Clearance
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PLEASE REVIEW ALL 3 SHEETS
Check # Date:
Receipt # Staff: rWj
PARCEL INFORMATION
Tax Map and Parcel: _ g(U 0 3 - i Q , 00 2-0 Existing Zoning
Parcel Owner: 1 -c L L C_. — -( t.
Parcel Address: `3 �� ���ti .� � l� 11-city (' k J U State (J(,
Zip
(include suite or floor)
PRIMARY CONTACT
Who should we call /write concerning this project? r� �� ek I -'F �-� t
Address: C1 C D- r,4lyt_ l I (L.J City j % js— State
Zip7 -:zA �-i
Office Phone: (_) Cell #CILG -S-77(. Fax # E -mail
APPLICANT INFORMATION
Check any that apply: (^ Change of ownership Change of use Change of name New business
Business Name /Type: �� �: [,� T"1- `r'GL.J� - )C S
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:
*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 Iocation, a new Zoning
Clearance will be required.
I hereby certify that wn 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 o e best of my knowledge. I have read the conditions of approval, and I understand them, and that•I will abide by them.
Signature r' Printed LA r1
APPROVAL INFORMATIO
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
Zoning Official Date 5 ?ol y
Other Official w� CAC-T) Date 5.1 1.11 •(.,3( "L•
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:
Reviewer to complete the following:
Y / Square footage of Use:
Is us m LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet. � / N
Permitted as: 4eA�2>r, t1 �FI�� r 2�J� ✓�S�
Y Otere Will be food preparation? Under Section: (�� ,,•, . �y,9
If so, give applicant a Health Department form. r
Zoning review can not begin until we receive approval from Health Supplementary regulations section:
Dept. FAX DATE
Circle the one that applies Parking formula:
Is parcel on private well or is er?
If private well, provide Healt ent form.
Zoning review can not begin until we receive approval from Health Required spaces:
Dept. FAX DATE
Y/
Circle the one that ap Items to be verified in the field:
Is parcel on septic public sew
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y/N
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the following:
Inspector:
Notes:
Date:
Violations:
/1V
If so, List:
offers:
Y/N
Yso, List:
%
Varia ce:
Y/
If so, List:
P's:
/N
If so, List:
Z
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Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3
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