HomeMy WebLinkAboutCLE200900079 Legacy Document 2012-08-30Application for Zonin Clearance
Is
CLE # 10tq %
Kzoning
OFFICE USE ONLY
Check # /0'31 Date: U
Clearance = $35
PLEASE REVIEW ALL 3 SHEETS
Receipt # 756 - Staff:
PARCEL INFORMATION
Tax Map and Parcel: -D /- Ve -ODoC_ 6 Existing Zoning
Parcel Owner:
Parcel Address: '- WO-1#0-r- enD 61 A6 City ef-to 44--Z State Zip'Z�K3
(include suite or floor)
PRIMARY CONTACT
Who should we call /write concerning this project?
Address: 0.0 h4 urn e. /_ A- City el-�g zcr7' State
Office Phone: G -437 /r Cell # .FDl� ` i'o29� Fax # ��,3 /�ZG E -mail �deiic�7 �c� da %k�STUc�s
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name /Type: /—OC 2 l�Q. G� �� �r� �c� ;e-
Previous Business on this site 14 $ 32
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: &",r ,Y wn fo" P quo / y nr _� i '
/n 7L' !s Rya% 4A=g4 mQC=4 Coin g ars�e�eA4E
e
*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,hqve the owner's ei on to use the space indicated on this application. I also certify that the information provided
by
is true and accurate to the es o y no led eve read the conditions of approval, and I understand them, and that I will abide them.
Signature Printed
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 corn lies )h t`e as o is date., � G D
Building Official '' Date
Zoning Official Date
Other Official Date
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902iVoice: (434) 296 -5832 Fax: (434) 972 -4126
Revised 04/28/08 Page 2 of 3
a
Eff =1
Intake to complete the following:
Y/N
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y/qWill 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 or public water?
If private well, provide Health Department form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Reviewer to complete the following:
Square footage of Use: q �-9 D
/ N
initted as:
Under Section:
Supplementary regulations section:
Av14
Parking formul :
� n(i `en-o
Required spaces:
Y/N '-
Circle the one that applies Items to be verified in the field:
Is parcel on septic or public sewer?
Y/N
., - 2,00 Lf - 4t
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit # Inspector : Date:
Y/N
Will there be any new construction or renovations?
If so, obtain the roper Permit.
Permit
7nnina to emmnlete the fnllnwinu-
Notes:
Violations:
Y/
If so, ist:
P ffers:
List:
(Po, N
Varia ce:
Y IrM
If so, ist:
S 's:
N
Pook
Clearances:
SDP's
Revised 04/28/08 Page 3 of 3