HomeMy WebLinkAboutCLE201200253 Legacy Document 2012-12-19Application for Zoning Clearance
CLE #
:� :; „� °f "``�
PLEASE REVIEW ALL 3 SHEETS
OFFICE US LY
Check # Date: c�
Receipt #3U_141 Staff:
PARCEL INFORMATION
Tax Map and Parcel: / —5 61 Existing Zoning /
/
Parcel Owner: v1 ✓ , C ✓� �� v��
Parcel Address: tye-& ✓n4 rT kt City C�A� /1-H-ell"' tate V14— Zip
(include suite or f 1 r)
PRIMARY CONTACT
Who should we call /write concerning this project? �t ✓� �o
/I�j(
/eJ�
/ /
''//o
Address : 17 D p ,r o ✓n S �� City C/�A / �� �/ �S ✓ -(t State (� Zip
Office Phone: (_� Cell # NT 9 �zs 0 ?3i Fax # E -mail �; rr� %rs ✓ °Rtya r o9
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
%
Business Name /Type: �'r� / r4_ / i •• , '7 3 V,_ /t .e -,
Previous Business on this site V_A
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: ,moo �n �ri or-c jigs✓- °vim �. -�k
*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 th ce indicated on this application. I also certify that the information provided
is true and accurate to the )est of my lmowledW9Q ditions of approval, and I understand them, and that I will abide by them.
Signature Printed Cti
AP OVAL INFORMATION
[ VT 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 �-
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 7/1/2011 Page 2 of 3
Intake to complete the following:
Y
Is u LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y N
Will'tlfere 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_th�
Is parcel on -�x�ell • ublic water?
If private well, provide Health Department form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applies
Is parcel or( , public sewer?
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y/N
W 1 ere 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:
ermitted as: "" W
Under Section: R (' 1 + a, � t
. I'
Supplementary regulations section:
Parking formula:
Required spaces:
Y/N
Items to be verified in the field:
Inspector:
Notes:
Date:
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
�
r
�
/ Revised 7/1/2011 Page 3 of 3