HomeMy WebLinkAboutCLE200900169 Legacy Document 2012-10-11QA\
Application for Zoning, Clearance
J=
CLE # 9-U Dq - 1(29
U
'1
VfROIN�P
kEVIEW ing Clearance = $35
OFFICE USE ONLY
Check # CA66 Date:
PLEA ALL 3 SHEETS
Receipt # `1 2(Q SS Staff: flu,(,��1
PARCEL INFORMATION
' 1 Existing Zoning �Y
Tax Map and Parcel: �J
Parcel Owner:
S oz g ,) UU n /�.� ,,��( q
Parcel Address: � �(O I°� r J D �O �" ft1 r / ` City L' L0 2 F- State ZipoC Z
(include suite or floor)
PRIMARY CONTACT a
l (n —rR('e T"
Who should we call /write concerning this project? f t9
--
Address :� ��' IJ I� �C 'y —D&TT D �Z<f) City 1. V� State V� Zip ® I
Office Phone:T J "11gN O1R � Cell #4 m �Z Fax # `7 � "� E -mail SQ66 6/n5Q f 9 '�
APPLICANT INFORMATION �-
Check any that apply: of ownership Change of use Change of name
� , •Ne�w,gbussiiness
`�CnhaCnge
Business Name /Type: f t I'� C A K D Lr rV T- f ly -C. a Q� °- J 0 1 3 W l' 1" /
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:
*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 Printed S (r O f 77Q, 1 Q
F 0672H
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 (0
Zoning Official Date /y /a/ L) %
`` 2 /8/01
Other Official G�� 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.
1 N
Will there be food preparation?
If so, give applicant a Health Department form.
Zoning review can not begin u til we receive approval from Health
Dept. FAX DATE
Circle the one that applies —\
Is parcel on private well or ublic water?
If private well, provide Healt ment form.
Zoning review cannot begin until we receive approval from Health
Dept. FAX DATE
Circle the one that ap public Is parcel on septic public sewer.
Y/N
Will you be putting up a new si of any kind? so, obtain proper
Sign permit. P 'rw o ti"` Lo •t C>
Permit #
Y N
i11 there be any new construction or renovations?
If so, obtain the proper Permit. T
Permit #
a G ,-
Zoning to complete the following:
Reviewer to complete the following:
Square footage of Use: ' qQ IS
IN � l
ermitted as:�
Under Section: ; , ' I
Supplementary regsa ions section:
Parking formula:
Required spaces: 1
Y/N
Items to be verified in the field:
Inspector:
Notes:
Date:
Violations:
Y/
If so, ist:
Prof rs-
Y/
If so, ist:
Vari e:
Y//N
If so, ist:
SP's:
so List: /
)� r bajn, IL
Clearances:
SDP's
Revised 04/28/08 Page 3 of 3