HomeMy WebLinkAboutCLE201200196 Legacy Document 2012-09-12Application for Zoning Clearance
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Clearance = $35
OFFICE USE ONLY
Check # Z�% w- �i Date: �" l�
PLEAZoning
REVIEW ALL 3 SHEETS
Receipt # Staff: /J1jx(( tf
PARCEL INFORMATION
Tax Map and Parcel: �j l l� 05 C XA Ck-- Existing Zoning f I v
Parcel Owner:
e 1
Parcel Address: City CU1G✓ oC'SY��� - State 1%!, Zip �%�
(include suite or floor)
PRIMARY CONTACT
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Who should we call /write concerning this project? ►1 ���V\ tl C
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Address: 2)r�IG�OOf�o \L".�, City C��I.J �b'c�CC' `1R�� State �/ Zip 2Z�1 \�
Office Phone: Cell # 430111-002-Fax # E -mail OlL.Izm(Y 0 %^Clls',1^Q�
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
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Business Name /Type: Kt� i \�fi(lf��l 1`1' \u���r0�y y�1�����G�� OR") u�
Previous Business on this site lam+ ecr—
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: ALL eLj0j0,jVj LGQ(lil\d - C � li .&
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PG �IG��t�h
*This Clearanaf will only be valid on the parcel 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 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.
Signature �� Printed
APPROVAL INFORMATION
>< Approved as proposed [ ] Approved with conditions [ ] Denied
[ ] Bacicflow 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 Date (1 l t I f Z
Zoning Official Date M L%Z
�.
Other Official Date
V
y — —ue.narie meparcment of Lommunity 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/a
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y / �N
Will there 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 wate ?
If private well, provide HealtltDepartment 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 �ufb is sewer?
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y/N
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
ZoninE, to complete the followintt:
Reviewer to complete the following:
Square footage of Use: 1 'T SCS �+
/N
Permitted as: /14u Q
Under Section: > •'L .
Supplementary regulations section:
Parking formula:
0 IV �
Required spaces:
Y/
Items to be verified in the field:
Inspector : Date:
Notes:
Violations:
Y /
If so, List:
Proffers:
Y �� �.
If ' ' List:
Variance:
Y /_N
If SOD
SP's:
Y/D
If so, List:
Clearances:
SDP's
Revised 04/28/08 Page 3 of 3
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