HomeMy WebLinkAboutCLE200900151 Legacy Document 2012-10-01Application . for Zoning learance
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A Zoning Clearance = $35
OFFICE USE ONLY
Check # ��� Date:
PLEASE REVIEW ALL 3 SHEETS
Receipt # l0 6.5 Staff:
PARCEL INFORMATION
Tax Map and Parcel: Existing Zoning f13'.m.c
Parcel Owner: I_ c'-� cg" L,;' 1 t s
Parcel Address: j,,6 z, . Q h4yeA City d fv e_ State W Zip �
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project ?,
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Address: 110 .� , i�o� - �z +s ��+� � City chtrr rSyL I I° State j)d Zip 22
Office Phone: � Zvi 5,6301'4 Cell # Fax # Zq -0g 47 C E -mail
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APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
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Business Name/Type: _ r.,, "° (AA Psi✓ . Ve./o 1211, ,, /i
Previous Business on this site
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 e,,,,„ ,,L, wu, .(J
*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.
Signature /4"11/i�....F�1- -14____. 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, 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
Zoning Official .° Date 16 4z
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:
Is/
Is us LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y /
Will re 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:
Y/N
Permitted as:
Under Section:
Supplementary regulations section:
Circle the one that applies Parking formula:
Is parcel on private well or public water?
If private well, provide 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/N
Will 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 / N Notes:
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit # '`.!- 9
Zoning to complete 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