HomeMy WebLinkAboutCLE200900200 Legacy Document 2012-10-15Application for Zonin Clearance
CLE #
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Zoning Clearance = $35
OFFICE USE ONLY J�
Check # Date:
PLEASE REVIEW ALL 3 SHEETS
Receipt # Staff: (=tl e Z
PARCEL INFORMATION
Tax Map and Parcel: 1 — / �4G/(/� Existing ZoninL DIN(f
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Parcel Owner: r
Parcel Address: 03 5e kmar 1..;l. City CV1adbft6Vik State V7-1 Zip2z�oj
(include suite or floor)
PRIMARY CONTACT H
km W 1 C I v -I wson or Lest i.e- WoCd
Who should we call/write concerning this proiect? .
Address : &73 �Qif' I� V�'1'�'r� City NAOfteS4 Z State VA Zip2270I
Office Phone: d�bbl-2 ]N) Cell # Fax ��4-I- J`� E-mail Acevnayaciere
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APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name/Ty pe: PWeAy) 'P)c+uty-g5, Inc. Lrq�H-5"(X vyv ucwov" R)wx,
Previous Business on this site E�5-1 'Fy'Dd,{Ach%; I Vl c ,
Describe the proposed business including use, number of employees, number of shifts, available parking spaces, number of
information 'DMCUAC -616
vehicles, and any additional that you can provide: U)- CE � Viuo
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5 yZh cl, . j20_ sPaC24
*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 to the best of my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signatu c Printed IS��� Wood-
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
Zoning Official Date b
Other Official Date
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 14126
Revised 04/28/08, 10/13/09 Page 2 of 3
Intake to complete the following:
l �
Is Y ifi 1 LI, HI or PDIP zoning?
Engineer's Report (CER) packet.
If so, give applicant a Certified
Y /
Will ere 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 pu lic wa er?
If private well, provide HeAQBe_p ment form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that appli
Is parcel on septic or lic se er?
Y/N
Will you be putting up a new sign of any kind?
Sign permit.
Permit #
If so, obtain proper
Y/N
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning -to complete the following:
Reviewer to complete the following:
Square footage of Use: 3y( 8
/N -
ermitted a
Under Section:
Supplementary regulations section:
a
Parking formula:
Required spaces:
Y/N 1
Items to be verified in the field:
Inspector : Date:
Jim / INI /mo r'e ' 4l afrl
Viol�io, :
Y /71
If so, List:
Proffers:
Y
If so, i ist:
Variance:
Y�
Ifs , ist:
SP's.
If /�
If so, ist:
Clearances:
SDP's
Revised 04/28/08, 10/13/09 Page 3 of 3