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HomeMy WebLinkAboutCLE201200105 Legacy Document 2012-07-13Application for Zoning Clearance CLE # 7012- I 15 a (� y OFFICE U�5l� ^O,,��VV�Y +B PLEASE REVIEW ALL 3 SHEETS Check # (.D�S`-t-"1 Date: Receipt # C Staff: PARCEL INFORMATION 7� Tax Map and Parcel:' 0 2)Z( j ^ n Z '� r ©Q Existing Zoning n� Parcel Owner: 12'" 6—)3 hn IL`s 1 / n Parcel Address: `T�O� 1�%e�i (�� City c_ 6 IV State V A Zip 2 (include suite or floor) PRIMARY CONTACT Who should we call /write concerning this project? t�J Ylhl 111'- -� Address : �i ?5- tl - City u+^`I1,,(, State �� - Zip Office Phone: (_� s —I> Cell # �r3S • �� ti( Fax # E -mail CV 'PLLQ5? co o. Ga w1 APPLICANT INFORMATION Check any that apply: _Change of ownership Changerof use . Changeeoof name New business ++ -9uo-1J Business Name /Type: • IM61a l40L SaQ�C, 0Sr_ • �iiJC�GT ��t� I u Previous Business on this site 1 40 tJ 4, Describe the proposed business including use, number of employees, n tuber of sh' t , availa arkin spaces, numb r of vehicl , an any a ditional i f rmation tkat you can pr vide: o 0 I o Z i S' *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 o i oz have the owner's permission to use the space indicated on this application. I also certify that the information provided is true and accurate t h bes of my klvledge. I have read the conditions of approval, q d I understand them, and that I will abide by them. O C Si nature Printed g APPROVAL INFORMATION >41 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 uhZ / /Za) L/ Other Official Date 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 LI Nt Intake to complete the following: Y/N Is use in LI, R or PDIP zoning? If so, give applicant a Certified Engineer's Report (CER) packet. Y/N Will 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 Circle the one that applies Is parcel on private well or public water? If private well, provide Health Department form. Zoning review can not begin until we receive approval from Health Dept. FAX DATE Circle the one that applies Is parcel on septic or public sewer? 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 # 7,nninu to complete the following: Reviewer to complete the following: Square footage of Use: W/N n I j Permitted as: *l D�Kr�I Under Section: Supplementary regulations section: Parking formula: Required spaces: YY /N Items to be verified in the field: Inspector : Date: Notes: Violations: Y/ A If soYist: Proffers: M/ N If so, List: Varia e: Y/ If so, List: SP's: Y/ If so, List: Clearances: SDP's Revised 7/1/2011 Page 3 of 3