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Application for ZoniN��
CLE # Z
0
Mzoning Clearance = $35
PLEASE REVIEW ALL 3 SHEETS
OFFICE USE
Check # ON Y
��� Date:
Receipt# i 20 ke Staff: cA
PARCEL INFORMATION
Tax Map and Parcel: Existing Zoning
Parcel Owner: V J'V PV b1I V PC
Li
Parcel Address: /UU�(/ 2�City /��l��G�f`f State !/ Zip 296
(include suite or floor)
PRIMARY CONTACT
Who should we call /write concerning this project? 1= iw n LE r�ov2�
Address : 31 S6 C'f? eu_USN Cam. City &/Jt4kLv77 -r5y1 rState Yid- Zip 22
Office Phone: Cell #727-ZY3 ('a Fax # E -mail 4e.wa,Ejvri Lb"wh t/ /v�rs
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name /Type: SC yga .b l V% 56yUP
Previous Business on this site U ut"vw y
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: 5Cu A# /n(S7". 9►- F- MPIoye,f
IT T Up-AS 'T- ),g- d2fi eglI✓6 PL/, G &S 16AIF— AIIS , V afi IC1- 9
*This Clearance will only be valid on the parcel for which it is approved. If you change, intensify or move the use to anew location, anew 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 Q.,,74W6 Printed :YA5,ni'l b, &aD
APRAOVAL INFORMATION
[Approved as proposed [ ] Approved with conditions [ f 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 iz'1 r O F
Zoning Official Date 0/;,g /��
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
,CC'm
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.
Y / 4er
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 public water?
If private well, provide Hea epa m ent form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applie
Is parcel on septic o uMe sewer?
Y /a
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y K
Wi IY ere be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
17 n rr +n rmm"ln +a +ha fnllnwina•
Reviewer to complete the following: -
Square footage of Use: 6q/ �Z. •p
/ N V� w l
-mitted as:
Under Section: ;?bA ,,1
Supplementary regulatio s section:
In 61
Parking formula: %!
Required spaceM
Y/N L
Items to be verified in the field:
iolations:
/
ZN
o; List: � op-7 — ys
Prof s:
Y/I
If so, List:
Var' e•
Y/
If s List:
SP's:
Y/ I
If so' sst:
Clearances:
SDP's
Revised 04/28/08 Page 3 of 3