HomeMy WebLinkAboutCLE200900050 Legacy Document 2012-08-27Application for Zoning Clearance_`°
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OFFICE US ONLY
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f Zoning Clearance = $35
PLEASE REVIEW ALL 3 SHEETS
Check #
Receipt # ' Staff:
PARCEL INFORMATION j�
911,400
Tax Map and Parcel: 6W1164-00-0y) - 00 Existing Zoning 1"
Parcel Owner: F (;"'Lo Ma
Parcel Address:— � OT ty)iQ n i l.rb State Zip
(incl de suit r floor) 131 Vg
PRIMARY CONTACT
Who should we call /write concerning this project? �✓ ._J
���tate
Address: City Zip
Office Phone: Cell r- f /�E -mail
APPLICANT INFO ON
Check any that apply: Change of o ership Change of use Change of name New business
Business Name /Type:
d
Previous Business on th site��1C�,r�• -�/��
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:
*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 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.
r
Signature `1/lil Y1 6,w Printed /�� ,� AJ 4'- 0
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, 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 c �---- Date
Zoning Official Sm Date Uq 17� I
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 04/28/08 Page 2 of 3
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Intake to complete the following:
Y
Is us m LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet,
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 t4 -1- O q
Circle the one that applies
Is parcel on private well or gublic 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?
Will'yyoou be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y 4N�
Will t��e"re be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the following:
Reviewer to complete the following: Q
Scare footage of Use: - J
Pe rtted as: �
c Vti
Under Section: �%J v �`S� Z� I `� ► �2,
Supplementary regulations section:
Parking form la: g) 00 ^ G r
Required spaces:
Y/N
Items to be verified in the field:
Violations:
Y/N
If so, List:
Proffers:
Y/N
If so, List:
Variance:
Y/N
If so, List:
SP's:
Y/N
If soi List:
J
Clearances:
SDP's
Revised 04/28/08 Page 3 of 3
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