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HomeMy WebLinkAboutCLE200900103 Legacy Document 2012-09-07Application for Zonin Clearance _�� °;` CLE # Z ®0 q - 3 � � ^` ��RGIN�P Zoning Clearance = $35 OFFICE USE ONLY Check # r66, 0fi Date: PLEASE REVIEW ALL 3 SHEETS Receipt # '756,30 - Staff -4�j z PARCEL INFORMATION : Q r °- �� "' Zoning Tax Map and Parcel: G' Existing Parcel Owner: Parcel Address: l � "-ftate VA-, Zi p ` ;�1/! / -- - - -- - - _- (include suite or floor) ' PRIMARY CONTACT i f�o f2leVI �� GAS Who should we call /write concerning this project9 Address: 1 9_10 5 O hells �� City 2 'r tuGGV� t l State L)pt- Zip A Office Phone: ` ,` CP° nAo Cell o0A -361 & Fax # E -mail APPLICANT INFORMATION Check any that apply: Change of ownership Change of use Change of name New'business Business Name /Type: SIn : �t fo (\ d14 4 Ctif_� Previous Business on this site R-, (d lC, �.0 4-0 7— Describe the proposed business including use, number of employees, number of shiftsnavailable parking spaces, number of 7` and any additional information that you can provide: / fiY l�l�/i �(ec a Y t yvehicles, y n 0S 1l. P n(_ S P OC . IYl fl s� W 9� c *This Clearance will only be valid on the patcel for which it is approved. If you change, intensify or move the use to anew location, anew 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 acc rata best my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them. l Signature C'�t l� Printed E5 2 Yom! S t)© Cosa lJ APPROVAL INFORMATION [ ] Approved as proposed [ ] Approved with conditions [ /nied [ ] 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 si plan as of this date. , otes: , Building Official Date C o� Zoning Official Date o S 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:. __._ . _._ _ _— _ _ °_ _Reviewer to complete the following: Y / Square footage of Use: Is usLI, HI or PDIP zoning? If so, give applicant a Certified Engineer's Report (CER) packet. Y / N Y/ Permitted as: Will ere be food preparation? Under Section: If so, give applicant a Health Department form. - - - Zoning review can not begin until we receive approval from Health Supplementary regulations section: Dept. FAX DATE Circle the one that applies Is parcel on private well otli�ater? Parking formula: SDP's If private well, provide Health Department form. Zoning review can not begin until we receive approval from-Health- -Required spaces: _ - __ Dept. FAX DATE Y/N Circle the one that applies Items to be verified in the field: Is parcel on septic or public sewer? Y Pyou Wil be putting up a new sign of any kind? If so, obtain proper Sign permit. Permit # - -- Inspector : Date: Y / Will(Dere be any new construction or renovations? Notes: If so, obtain the proper Permit. Permit # 7oning to comnlete the following: 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