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HomeMy WebLinkAboutCLE201500108 Application 2015-06-05Application for Zonin Clearance N CLE# 10- orFlcE Check # Date: mut, PLEASE REVIEW ALL 3 SHEETS Receipt # Staff: PARCEL INFORMATION n "�bl� )JxistingZoning TaxMapandParcel:�A1ui Pal -eel owner: 5 nlno(e- c'cc11e� LLe_ Parcel Address: I(% r5CM(A0k0 4&C 64e— 20 City C:vlGel�tffiAllk1e State Zip 2ZR0k (include suite or floor) PRIMARY CONTACTllll Who should we call/write concerning this project? �O36,VF lT f'4 Address: �Z�7 City %'t &,r(C yt State \h2 Zip \ ,Va�X Office Phone: ( D75a Cell # Fax #g __E -mw eto46h9&wn 1?7w)Aq}k i APPLICANT INFORMATION Check any that apply: Change of ownership of use Change of name New business _Change �Dn tr�'C��e�iL `�� 'j'nL' �pt�lf, 406451 t�G►�15�'L� Business Name/Type: Previous Business on this site Describe the proposed business including use, number of employees, number of shifts, available parking s aces, number of vehicles, and any a__dcc�'tional information that you can provide- 'A � � any GJt ehc�se l N — 5 ,:v� IA *This Clearance will only be valid on the parcel for which it is approved. If you change, intensify or move tie 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 accurate to the best of my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them. Printed �Z08E�T f-4' jC Signatures 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. inspection has been done for this clearance. Therefore, it is not a determination of compliance with the existing [ ] No physical site site plan. • I [ ] This site complies with the site plan as of this date. Notes: Building Official Date G Date Zoning Official Other Official Date 4.-F 0—mnnifv nPvP.1nnm P.nf VV4l1 Lx Ul n,wwuau ,Vrel+... ............--______�____� , 401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (434) 972-4126 Revised 7/1/2011 Page 2 of 3 . Com✓► v Intake to complete the following: Reviewer to complete the following: /-1, / N Square footage of Use: 7lb 93 se in LI, HIor PDIP zoning? If so, give applicant a Certified Engineer's Report (CER) packet. / N. Pv-mitted ' ('01 6Af as: Y tre Will be food preparation? Under Section; If so, give applicant a Health Department form. Zoning review can not begin until we receive approval from Health Supplementary regulations section: Dept. FAX DATE Circle the one that applies Parking for►nula: / Is parcel on private well o pu.bli2jiter? If well, provide I-ieaal��e7inent form. SDP's private Zoning review can not begin until we receive approval from Health Required spaces: Dept. FAX DATE /N Circle the one that app es-- -? 6ibli Items to be verified in the field: Is parcel on septic or werr Revised 7/1/2011 Page 3 of Y/N Will you be putting up a new sign of any kind? If so, obtain proper Sign permit. Inspector : Date: Permit # Y/N Notes: Will there be any new construction or renovations? If so, obtain the proper Permit. Permit # Zoning to complete the following: Violations: Y / 1TGI If so, st: Proffe : Y / If so, ist: Variance: �/N If so, List:✓, S 's: C If so, List: 6 y �/ Clearances: SDP's Revised 7/1/2011 Page 3 of G.- M 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, c- c(Xl "I Ur ZfMI✓kCk C «nGe [County application name an umber] the owner of record of Tax Map was provided to 1 [name(s) of the record o ners of the parcel] and Parcel Number Ob 1 3©0Qj !300 by delivering a copy of the application in the manner identified below; Hand delivering a copy of the application to i ✓Vi CJ'�4i �br [Name of the record er 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 recofd?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 or the owner as snvwu uL, the current real estate tax assessment books or current real estate tax assessment records satisfies this requirement]. Signature of Applicant Print Applicant Name Date greenbriar ?1 - IN IN _L2a�- a)vna5 9 I!a!4xzl aueaa uaajneW 1 ION :91ON Note: