HomeMy WebLinkAboutCLE201200205 Legacy Document 2012-09-27•
Application for Zoning Clearancer,:r`
Tit Ot i \l.(k.�r
CLE # 2011- , ?-65
OFFICE USE ONLYs i
# Date:
PLEASE REVIEW ALL 3 SHEETS
Check
Receipt # ✓ Staff: 1i t 5
PARCEL INFORMATION
Tax Map and Parcel: 9 5 oo "6C) — 60 —(-),2t66 Existing Zoning
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Parcel Owner:
l'ti; ��l ��i t City ���,re SJtState V C<. Zip ZZz
Parcel Address:���
(include suite or floor)
PRIMARY CONTACT
Who should we call /write concerning this project?
Address: -�We -" L'f %only City/ State Zip
u S DUCT �,
Office Phone: (.�-; ) .223Ya1 Cell # � `I 3 Fax # a�3-BIG E -mail
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name /Type: /" z, le lk
Previous Business on this site
Describe the proposed business including use, number of employees, number of shifts, available parking spaces, number of
t
vehicles, and any additional information that you can provide: C-v —o 2e
*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, anndll understand them, and that I will abide by 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, x117.
[ ] 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 ILi l°L
Zoning Official Date 5Z- 0 2;6) -z,/
Other Official Date
County of Albemarle liepartment of Uommunuy Leve,ul„ue,«
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
Revised 7/1/2011 Page 2 of 3
eS,C4--,
Intake to complete the following:
Y/N
Is use in LI, HI or PDIP zoning?
Engineer's Report (CER) packet.
If so, give applicant a Certified
Y / N
ll 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
Reviewer to complete the following:
Square footage of Use:
/N n
ermitted as: -4 � I �444L,
Under Section: .191kc/ b
Supplementary regulations section:
Circle the one that R ies ilarxing rormuia:
Is parcel on rivate well or public water?
If private well, p e Health Department form.
Zoning review can not begin until we receive approval from Health Required spaces:
Dept. FAX DATE
Circle the one that applies
Is parcel on septic or public sewer?
Y /
Wil you be putting up a new sign of any kind?
Sign permit.
Permit #
Y/N
Items to be verified in the field:
If so, obtain proper
Inspector : Date:
Y / 'Q Notes:
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
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Viol�ions:
If o
s/Z
Proffers:
A
If so—,List:
Varq ce: SP's:
Y/Ci
If so, List:
�/N
so, List:
Clearances:
SDP's
Revised 7/1/2011 Page 3 of