HomeMy WebLinkAboutCLE200900003 Legacy Document 2012-08-22Application for Zoning Clearance
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CLE # D r 5
OFFICE USE ONLY
XZoning Clearance = $35
Check # c'/, &41 Date:
PLEASE REVIEW ALL 3 SHEETS
Receipt# 7��.'' Staff:
PARCEL INFORMATION
.- G IUoO Existing I' SC
Tax Map and Parcel: 0 7 6`,f y- c7c) -OC7 g Zoning
Parcel Owner: F' k" w 6(,C
Parcel Address: 3 y �z 52- i4vk T;e+ f' S city /I State k4<- Zip
(include suite or floor)
PRIMARY CONTACT ..-_.
---, �/t �R L,5 YO
Who should we call /w,' riite concerning this project?
Address :.Q -2 Va4- f (C-77A " " City LO "e-3rel - State Zip's
Office Phone: 6 B Cell kW(z"7Y$ Fax # 975'r &Z `- E -mai
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name /Type: S LR C�L—Q RM ��-
�&mu
V'
Previous Business on this sittee ; 46,,r -c,s
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: u.t
*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 to se the space indicated on this application. I also certify that the information provided
is true and accurate to the of my know ge d the conditions of approval, and I understand them, and that Iwill abide by them.
Printed L. 9 �SaA j
Signature --, � � y
ROVAL INFORMATION
[ ] Approved as proposed [, ] Approved with conditions [ ] Denied
[` ] Backflow prevention device and /or current test data needed for this site. Contact ACSA, 977- 4511, -x119.
[ ] 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 Z
Other Official Date
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
,;;t Revised 04/28/08 Page 2 of 3
Intake to complete the following:
Y 'V
Is use in LI, HI or PDIP zoning?
Engineer's Report (CER) packet.
YO
If so, give applicant a Certified
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 public wate
If private well, provide Hea ar ment form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Y/N
Items to be verified in the field:
If so, obtain proper
Inspector : Date:
Y Notes:
Wi lere be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Circle the one that ap
Is parcel on septic f public sewer
Y
Wi ou be putting up a new sign of any kind?
Sign permit.
Permit #
Reviewer to complete the following:
Square footage of Use: C � 3
Permitted as: r (i f (.�•� l
Under Section: J
Supplementary regUlotions section:
to I.0%
Parking formula:` /Jyv
Required spaces: 6
Zoning to complete the following:
Viol s:
Y/NN
If so, Lis� r
Al A �I
Proff s:
Y/
If so,-List:
Va ' ce:
Y�
If so, List:
SP's:
Y�
If so, List:
Clearances:
SDP s
Revised 04/28/08 Page 3 of 3