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Application for Zoning Clearance
CLE a 0101
_
PLEASE REVIEW ALL 3 SHEETS
OFFICT USE NLY
Check # CMDate:
Receipt fl staff: G eLr
PARCEL INFORMATION F �5 G
5
Tax Map and Parcel: oq eo - UO- 00-a94AOExisting Zoning
Parcel Owner: SGT QAQ 1A \ %-\.. "IL
Parcel Address: 1g66 1Z to 1a%tAa a7rr- Clty L++NtitA9MCl6ttale VA I.ipZ24o 11
(include suite or floor)
PRIMARY CONTACT
Who should we eaWwrile concerning this project? WAN 41411.4 0 S U?G t reSQ .
Address: 1Z6 GA40rd S= City '44 zip?Z9oZ
Office Phone: 4-ft 249.9134 Cell # St> hvw- Fax a ara E-mailMa►yyyich A
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APPLICANT INFORMATION
Check any that apply: Chaa of ownership Change of use Change of name New business
Business Namerl)W: Q. TtaEJYl.Ptt LT
Previous Business on this site Ar-m e !& QAC.11C, a saw - R tii3 tM.�l�lktl•t'i
Describe the proposed business including use, number or employees, number of shifts, available parking spaces, numher of
vehicles, and any additional information that you can provide: 43Ayyy¢ M
CAA &UA to - 'm t 151�
* 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 owners permission to use the space indicated on this application. 1 also certify that the information provided
is true and accurate to the best of my knowledge.) Liave read the conditions of approval, and 1 understand them, and that I will abide by them.
Signature Printed Ni14`itJ►rtellt_�i3�i„
APPROVAL INFORMATION
j Approved as proposed { j Approved with conditions j Denied
j J I�aekflow prevention device and/or current test data needed for this site. Contnct AC,SA, 977.4S I I , x 117.
j o physical site inspection has been dome for this clearance. Therefore, it is not a determination of compliance with the existing
site plan.
j j This site complies with the site plan as of this date.
Notes:
Building Official Date / 2 1
Zoning Official Date
Other OMcla{ �_ Date C I De I tR
L;ounly of Ajoemarte uepartmettt of •.ummmnty uevcwpmcnt
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (434) 972-4126
Revised 1 1/02/2013 Pngc 2 of 3
I
Intake to complete the following:
Y
Is Ln LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
VN
ill there be food preparation?
If so, give applicant a Health Department form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE S, I b.1I) (I,E: U l l — 9 y
Circle the one that applies
Is parcel on private well o ublic w ?
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 applie
Is parcel on septic or blic sewer?
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit# WOV14 i? uli2 SLpe�G1FC �t�(yrit
Y/N
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
\N euk ci r`i'G�tJ1r� S(peiAye PC+m1+
Zoning to comDlete the following:
Reviewer to complete the following:
Square footage of Use: 3 oo ,, fi'L
'isermitted as: n� f S q W li k ov qt
Under Section: (I)
I
Supplementary regulations section: ( -,)0 )
Parking formula: p�CG
Required spaces
N) 1te be verified in the field:
Inspector: Date:
Notes:
Violations:
Y/N
If so, List:
r e d
Proffers:
Y/N
If so, List:
2OO -ZU
Variance:
Y/N
If so, List:
C�
VA 2��4_
SP's:
Y/N
If so, List:
2a0°� —3 i
Clearances:
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SDP's
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2 o oo -- 116
Revi sed 11 / 1 /2015 Page 3 of 3
EXHIBIT A
TO
LEASE
Site Plan
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S:\Rosenthal\Rio Hill\The Brick Oven\New Leasev3.doc