HomeMy WebLinkAboutCLE201200112 Legacy Document 2012-05-30Application for Zon�n Clearance
OFFICE US
PLEASE REVIEW ALL 3 SHEETS
Check #
Receipt # Staff:
PARCEL INFORMATIQN
0-7 i��`�' L��r �� - � ��% � Existing Zoning
Tax Map and Parcel; �
;Parcel Owner: �-' Y t" � U 71'� U o
r {
Parcel Address: Ll rw� . 9 City �'.,�+ c,,,, t- -L?ry k V l State ( Zip I
(include suite or floor)
PRIMARY CONTACT
(-, S
15!ho should we caIlhvrite concerning this project? 4 r\.10-1
Address: rZ ,� City L, 5 c r5 , tL_A,, State �� Zip 2 Lcic t
Office Phone: {�, Cell#q(- 0-5'120 Fat # E -mail
.APPLICANT INFORMATION
Cheek any that apply: Change of ownership _ of use Change of name New business
^Change
Business Name /Type: 5-
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 iris approved. If you change, intensify or move the use to a new location; a .new-Zoning
Clearance will be required.
I hereby certify that l own or have the owner's permission to use the space indicated on this application, I also certify that the inforinntion provided
is true and accurate t to best of my knowledge. I have read the conditions of approval, and I understand them, and that Twill abide by theta.
Signature Punted
APPROVAL INFORMATION
[ ] Approved, s proposed [ ] Approved with conditions [ ) Denied
[ ) Bacldlow prevention device and /or current test data needed for this site. Contact ACSA, 9774511, 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
Other Officials --'�" Date�1?1�-
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401 McIntire Road Charlottesville, Vey, 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
Revised 7 /1/2411. Page 2 of 3
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