HomeMy WebLinkAboutCLE201200091 Legacy Document 2012-05-30N
Application for Zoning Clearance
CLE # 20 l 2 �I l
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OFFICE US LY
4,24,12-
PLEASE REVIEW ALL 3 SHEETS
Check # Date:
Staff:
Receipt #
PARCEL INFORMATION
Tax Map and Parcel: Existing Zoning
Parcel Owner:L�n.'�'Lv�S c� -,.�� l.i,C . — �c� �i�Gti ✓-✓ "�
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Parcel Address: C OJ t`1 �7� 2J . City C'_ln'vi [•U State V Gi .. Zip 4zl 1 /
(include suite or floor)
PRIMARY CONTACT
Who should we callhvrite concerning this project?
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I i LAS State G zip ZZQL
Address : 01� l* ��- y,�✓J�t 1 l aJ City CL� W y
Office Phone: L_) Cell # CI w' 5 7 LL Fax # E -mail
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name /Type:
Previous Business on this site C A'
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 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 acairate to t best of my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature Printed (--A/,
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.
[ J This site complies with the site plan as of this date.
Notes:
Building Official Date
Zoning Official Date
Other Official - , �� Date 5-1 l"1l iZ
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
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Intake to complete the following:
Y/N
Is use in LI HI or PDIP zoning?
If so, give applicant a Certified
Reviewer to complete the following:
Square footage of Use:
Engineer's Report (CER) packet.
®l N
Permitted as: ��A� an�r¢ /c°� --t ✓e W o ✓1`
Y/N
Will there be food preparation?
Under Section:_7�Y,q
If so, give applicant a Health Department form.
1
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 p is er?
If private well, provide Healt De ent form.
SDP's
Zoning review can not begin until we receive approval from Health
Required spaces:
Dept. FAX DATE
Circle the one that applies
Y/
Items to be verified in the field:
Is parcel on septic or ublic serve
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Inspector : Date:
Y / N
Notes:
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoninp to com lete the followin :
Violations:
(_�/ N
If so, List:
roffers:
V/ N
If so, List:
Var' nce:
Y/
If so, ist:
SP's:
iZ /N
If so, List:
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3
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