HomeMy WebLinkAboutCLE201300080 Legacy Document 2013-05-03Application for Zoning Clearance���1�.
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OFFICE U ONLY
PLEASE REVIEW ALL 3 SHEETS
Check # Date:
Receipt # 0M Staff:
PARCEL INFORMATION
Tax Map and Parcel: � Existing Zoning
Parcel Owner
Parcel Address: f E 12-J 0 RD city cl -CLr 100"S'Al . State \M Zip2?cl01
(include suite or floor)
PRIMARY CONTACT
6e-o ,CW S off'
Who should we call /write concerning this project?
Address: �� �� �l I �- D City i ' ' State VA zip 3'� 42-
Office Phone: L� Cell #�O�i -��1z- 3BSFax # E -mail SOK0 0 Amer �► Qn'giL z to
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use �/1_Change of name New business
/�
Business Name /Type: SC�o I� p"� -+`IO �yi" / &A /` 1%' A
Previous Business on this site Iii naq p+ 3 L c--
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:
1
*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 t I own or have t wner's permission to use the space indicated on this application. I also certify that the information provided
is true and accura ee o the best of my wledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature Printed <1 Ed,
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 `{� 1 ( I
Zoning Official Date
Other Official Date
County of Albemarle Department of �_ommumiy Levewp,r►e,►L
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
Revised 7/}/2011 Page 2 of 3
Intake to complete the following:
Y
Is use m LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y /
Will Mere 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 o u water If private well, provide Healtepartment form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that a
Is parcel on septic public sewer?
YQ
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y(N
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
7.nnina to vmmnlPtP the following:
Reviewer to complete the following:
Square footage of Use: /!! 0,;i14 �Coun E✓ I Al yen rS�
l N AG (,ZsS6Y7 �a sej �� A
Permitted as: Ma+- r
Under Section: � • 2 •1 C!J
Supplementary regulations section:
Parking formula:
Required spaces: 1-7
Y/N
Items to be verified in the field:
Inspector : Date:
Notes:
Violations:
6�/N
If so, List; // 11 I(I1
?at
Proffers:
Y/N
•If so, List:
,B-'�ik7
Variance:
Y/N
If so, List:
SP's:
Y/N
If so, List:
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3