HomeMy WebLinkAboutCLE200900146 Legacy Document 2012-10-01Application for Zoning Clearance
�� °r "`f
CLE # — P
y� . x
��R6IN�P
Clearance = $35
OFFICE USE ONLY
Check # 51Q152(001 2(001 Date: `q'
PLEAZoning
REVIEW ALL 3 SHEETS
Receipt #'1 Staff: 41 JtV4
PARCEL INFORMATION
Tax Map and Parcel: T)SW00— Op— 00— 111) bb Existing Zoning �'' ► �
Parcel Owner: l(b,Q� - A kywis S , l�!
Parcel Address: 55 j) -VQ 1 , . City CIAU 0 ftV't<<Q State Zip Q
(include suite or floor)
PRIMARY CONTACT
Who should we call /write concerning this project?
Address : ��llp��l� �31vd City �$ta Cl te 1V Zip i _ i •!'
3319 17 33
Office Phone: 63to 7133a°k_,Pell # _7'7 Fax # 140= E -mail _Sg1YQ�s (R)
APPLICANT INFORMATION - - - 30A V - - - - -- - -- - -
Check any that apply: Change of ownership Change of use Change of name New business
Business Name /Type: i �'�
Previous Business on this site
Describe the proposed business including use, number of employees, umber of shifts, available p rking spaces, number of
vehicles, and any additional information that you can provide: d i
C► r
a
*This Clearance tvill on Ty be valid on the parcel for which it is approved. If you change, intensify or move the use to anew 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 ac e e e. I hav e read the conditions of approval and I understand them, and that I will abide by them.
�y.kno-w-Lo_d
-
Signature - Printed
APPROVAL INFORMATION
[ ] Approved as proposed [ k1 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 co replies with thy( site plan as of thi ate.
Notes: i GUb 1; !tom -C2 vet 2 G�t� I�-I Jx l�
Building Official - Date
Zoning Official Date
Other Official Date
County of Albemarle Department of Community Levelopment
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
Revised 04/28/08 Page 2 of 3
t(�a�
.CCN N\
Intake to complete the following: Reviewer to complete t e following:
Y / Square footage of Use: cl
Is uI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet. M/ N
rmitted as:
Y/N
Will there be food preparation? Under Section: p2.
If so, give applicant a Health Department form.
Zoning review can not a in u til we receive approva)�D�Health Supplementary regulations section: /j
Dept. FAX DATE ! (/y
Circle the one that applies v/\ Parking formula: (
Is parcel on private welhor is wa er? n I�
If private well, provide Health Depa' ent form. .
Zoning review can not begin i e receive approval from Health Required spaces:
Dept." FAX DATE -
Y/N
Circle the one that applies •Items to be verified in the freld:
Is parcel on septic or p lic se r?
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit # Inspector : Date:
,
Y/N N90s.,
Will there be any new construction or renovations? C`
If so, obtain Mi proper Permit. -
Permit # VyN
an
G(,t s /alt r
Zoning to complete the following:
Violations:
Y/N
If so, List:
Proffers:
Y/N
If so, List:
CA
Variance:
Y/N
If so, List:
SP's:
Y/N
If so, List:
Clearances:
SDP's
Revised 04/28/08 Page 3 of 3