HomeMy WebLinkAboutCLE201200148 Legacy Document 2012-07-13• • •
Application fo Zon Clearance -
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CLE # ✓
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OFFICE U + O X
PLEASE REVIEW ALL 3 SHEETS
Check # Date: - o
Receipt # Staff:
PARCEL INFORMA
Tax Map and Parcel: Existing Zoning 4,0
Parcel Owner: C tO,
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Zi a
Parcel Address: Cit State ui
(include suite or floor)
PRIMARY CONTACT
Who should we call /write concerning this project?
Address :tIb i �r�>� �4.J` City , 1 State �- ZiO�GN
o3 #1ft Fax # E -mail
Office Phone: ( Cell
X13
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
Describe the proposed business including use, number of employees, num er of shifts, available parking spaces, number of
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vehicles, and any additional inform tin hat you can prov'd ` 1
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*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 accur a tot best of my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature C Printed
APPROVAL INFO ON
] 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 I l�
Zoning Official Date :71/3&_0)Z,
Other Official Date
County of Albemarle Department of community Deveiopment
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
Revised 7/1/2011 Page 2 of
1
Intake to complete the following:
Y/N
Is use in LI, HI orPDIP zoning? Ifso, 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 er?
If private well, provide H ment 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 r?
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 #
Zonin to com lete the followin
Reviewer to complete the following:
Square footage of Use: % 7
Y / N
Permitted as:� LIP
Under Section:
Supplementary regulations section:
Parking formula:
Required spaces:
Y/
Item be verified in the field:
Inspector : Date:
Notes:
Violations:
Y/
If so, List:
Proffe
Y
If so, List:
Variance:
0/N
If so, List: U5
SP's:
n/N
f so, List: 4, n
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3