HomeMy WebLinkAboutCLE200900100 Legacy Document 2012-08-31Application for Zoning Clearance
CLE #1009 ~- / ®0
n
�IRCIN�P
1911�0'ning Clearance = $35
OFFICE USE ONLY
Check # /02- 0 Date:
PLEASE REVIEW ALL 3 SHEETS
Receipt # '75 S- Y S Staff:
PARCEL INFORMATION l
Map Parcel: — 0-5 ` ®a ° Wa D O Existing Zoning �GrY�i'r1
Tax and 0:7 oco
Parcel Owner: ,:1 Pe- rrc%nu Duo- &I-cla-
C
Parcel Address: 5 � f FC'k l corleV- bri�a c City t itt- State V4, Zip ;t-)-q
(include suite or floor)
PRIMARY CONTACT ` , f ii'' '11- _
J/C V + P �b C6 i=
Who should we call /write concerning this project? iwy_ i
Address : 5� 5 6,,,'U m5 lcr ej City Char o k V t I � State VA- Zip 03
X 2 �t3y- 9121 5Nas` ti
Offlce Plione: Lg3q) 9 & ? °D3ay Cell # 70-7F32 Fax # E -mail
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name w business
V
Business Name /Type: �) 4 �► "I t P• D, C [�
Previous Business on this site :�-6m-d�—o(�
Describe the proposed business including use, number of employees, number of shifts, available parking spaces, number of
it Lv Z
vehicles, and an additional information that�,yyou ca rovide: U rs pe rso n
t o h as-e—I A a & �Rct
ha Gh,adby ec5 sa0
*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. T also certify that the information provided
is true and accurate to the blle,,,,stt of my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature ZZd_1 �x, JV . Ye E 10) Printed bkh ne. W, V a'I+
AP ROVAL INFORMATION
[ V1 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 Dated
Zoning Official Date r!O 12J, 1,9q
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 o complete the following:
Y N
Is n LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y /
Will 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 up blic _�yatex? -..
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?
Y /G
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y /�2Wil ere be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the followine:
Reviewer to complet -t—M
Square footage se: i o )(
N
1'lsrmitted as:
Under Section: I
Supplementary regulations section:
�C U
Parking formula:
Required spaces:
YIN
Items to be verified in the field:
Viol • ns:
Y /
If so List:
Proffers:
Y /
If soV :
Vari ce:
Y/
If scist:
SP's
Y/&
Ifs , List:
Clearances:
SDP's
Revised 04/28/08 Page 3 of 3