HomeMy WebLinkAboutCLE200900074 Legacy Document 2012-08-30Application for ZoninLy Clearance
CLE #
�'IRGLN�P
Zoning Clearance = $35
OFFICE USE ONLY
Check # 0 n 7 G Date: �'�'
PLEASE REVIEW ALL 3 SHEETS
Receipt # Staff:
PARCEL INFORMATION
Tax Map and Parcel: —! L 1 q ,3J 00o t OUV Existing Zoning SV` PP-`O_
Parcel Owner: w%, ILA ..� C..� —C-
Parcel Address: 3 L( `-I City " 'V' 1 u State %%w Zip t�
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project? l n
Address: 1�1 (-e- cP � � (� City I%s P cal` State V ZipZZgq 7
Office Phone: U '_ `� Cell # i �� "S� Lt; Fax # E -mail
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name /Type: G-rc J3' I(-
Previous Business on this site rv��w� -` ` G'Y' i < �(' F
Describe the proposed business including use, number of employees, number of shifts available parking spaces, number of
i�""
vehicles, and any additional information that you can provide: %-I r�4 ✓Ic-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 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 t best of my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature 4 Printed
APPROVAL INFORMATION
[ ] Approved as proposed [ t/�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 co plies w ;�'tapi the site plan as of this date.
Notes: U�l vYt r" �t 12.- 0
61 wn ZI ENV
Building Official_ Date
Zoning Official Date
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
Intake to complete the following:
Y /0
Is use in LI, HI or PDIP zoning?
Engineer's Report (CER) packet.
If so, give applicant a Certified
Y /Ti
Will :t ere 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 o ub ' 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 applie
Is parcel on septic or ubli sewer?
Y/N
Will you be putting up a new sign of any kind?
Sign permit.
Permit #
If so, obtain proper
Y
Wil/1l 1
t ere be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the following:
Reviewer to complete t e following:
Square footage of Use: O(
ermitted as: Ci S6 5�
Under Section: k
Supplementary regulations s ec ti n
Parking formula: 4 ;� " r ^
Required spaces:
Y/N
Items to be verified in the field:
Inspector:
Notes:
Date:
Violations:
Y/N
If so, List:
Proffers:
Y/N
If so, List:
Variance:
Y/N '
If so, List:
SP's:
Y/N
If so, List:
Clearances:
SDP's
Revised 04/28/08 Page 3 of 3