HomeMy WebLinkAboutCLE201200258 Legacy Document 2013-01-02I
Application for Zoning Clearance dfzy
CLE #
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PLEASE REVIEW ALL 3 SHEETS Chcctt # Dntet
Receipt 11 stnfr:
PARCEL INFORMAT N
Tax Map and Parcel: �,�- °�--- Xisting,Zoning�
Pnrcel Owner: ' 2
Pnrcel Address:i t Z�
,9s rr t tate !I zi
Include suite or floor)
PRIMARY CONTACT c C U }-- Who should we call /write concerning this project? d
Address : 1 %7 l� ,I'r3t. e:.��f
r3 Lc /Ili City � � State. t�i1 zip
Office Phone: t/( • t tJ Cell # 99 14QFnx# q72-102-- 3� B -111011
APPLICANT INFORMATION
Check any that apply: Change of ownership Chunge of use Change of name New business
Business Name /Type:
Previous Business an this site
Describe ti:e proposed business including use, number of employees, number of shifts, available panting spaces, number of
vehicles, and any additional information that you can provide:
*This Glearance will oply 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 0""' 0 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 t est of my knowle ge, I have read (lie conditions of approval, and I understand them, and that i will abide by them.
signature Printed
APPROVAL INFORMATION Denied
Approved as proposed [ j Approved with conditions [ )
[ ] Backfiow prevention device and /or current test data needed for this site. Contact ACSA, 977 4511, xl l7.
[ j No physical site inspection has been done for this clearance. Therefore, it is not a determination of compliance with the ox t;ng
site plan.
[ j This site complies with the site plan as of this date.
Notes:
Dnte
Building Official
Zoning Official ,Gr.�+� ' Date „ ?Z�z/ p1
Other Official ,� Date Z L,
County of Alb arlc Depnrtjnerit of Comnuutity Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Tax: (434) 472-4126
Raviscd,,7 /l /2011 Page 2 of 3
Intake to complete the following:
Y/N
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
W/N
ill there 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 / 2,�l�Zd J L
Circle the one that applies
Is parcel on private well orb blic wat r?
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 on septic or pyb c ?
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 #
Zonin to complete the following:
Reviewer to complete the following:
Square footage of Use: ! 7Y
�/N
ermitted as: n
Under Section:
Supplementary regulations section:
Parking formula:��
U
Required spaces:
Y/
Ite o be verified in the field:
Inspector:
Notes:
Date:
Viol tions:
Y/
If so, ist:
Proffers:
If/(
If so, ist:
Varia. ce:
If s/o;� ist:
SP's:
Y /(�
If S/ L's t:
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3