HomeMy WebLinkAboutCLE201200181 Legacy Document 2012-08-31Application for ZoniinLy Clearance``r
CLE #
OFFICE U F+� QNLY
PLEASE REVIEW ALL 3 SHEETS
Check # 1�j Date:
# Staff:
_.Receipt
1 /'
PARCEL INFOR�;T- �/ Existing Zoning�l.,l'�
&W.4, � m
Tax Map and Parcel: �
-
, r
Parcel Owner: J
"I Ile State Zip
Parcel Address: City i
(include suite or floor)
PRIMARY CONTACT
Who should we call /write concerning this project?
Address: AW % ZzeSCZ City State Zip t
Office Phone: ,yJ�° %3 Cell # -1J4 6 ✓.Y42Fax
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name /Type: eo�;�'7; ,IZ
Previous Business on this site Ao10Xs,
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: /i'`�G� �-
*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.
Printed
Signature � .
APPI� VAL INFORMATION
Approved as proposed [ ] Approved with conditions [ ] Denied
[ ] Backflow prevention device and /or current test data needed for this site. Contact ACSA, 977 -4511, x117.
[ J 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 51 z- �;? 6f Z
Other Official Date
County of Albemarle Department of uommumty lieveiopment
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
Revised 7/1/2011 Page 2 of 3
S
Intake to complete the following:
Y f NI
Is us m LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y CfFi
Wil 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 ublic water?
If private well, provide Health apartment form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Reviewer to complete the following:
Square footage of Use: 0-
./N /
Permitted as:
Under Section: 'L�i •�
Supplementary regulations section:
Circle the one that applies
Is parcel on septic or public sewer?
J/ N
Will you be putting up a new sign of any kind?
Sign permit.
Permit# U)
Parking formula: �'
I,y . ti
Required spaces: /
Y/N
Items to be verified in the field:
If so, obtain proper
Inspector : Date:
Y / Notes:
Wilptere be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the following:
Violations:
(Z)/N
If so, List:
Proff rs:
Y/
If so, ist:
Varian
Y /(
If so, List:
SP's:
Y /O
If so, List:
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3