HomeMy WebLinkAboutCLE201300095 Legacy Document 2013-05-22A ,
1 �
Application for Zoning Clearance
CLE #
PLEASE REVIEW ALL 3 SHEETS
OFFICE U . � O LY
Check # C06i. Date: • ��
Receipt # Staff:
PARCEL INFORMATION
Tax Map and Parcel: Existing Zonin
Parcel Owner•
Parcel Address: City )4�.Alfj(�btate Zip
(include suite or floor)
PRIMARY CONTACT �a /�
�
Who should we call /write concerning this project? � 1_1 �`�
PfkN)A 0
Address: 6,0�_ City State V Zip
J � W
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Office Phone. .� /ell # lx # E -mail �//�, /�.���
•° /v" v MIT
APPLICANT INFORMATION ;
Check any that apply: Change of ownership Change of use Change of name New business
Business Name /Type:
!r`
Previous Business on this site
Describe the proposed business including use, number of employ , , .ber of le parking spaces, number of
vehicles, and any additional information that you can provide:
*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 certi that I own or have t e owner's permission to use the space indicated on this application. I also certify that the infor ion provided
is tr a and a nto, e e of owledge. I have read the conditions of approval, and I understand them, and that II will ab' e b t
Signature Printe ! 1Y l Y ✓(� �-
APPROVAL INFORMATION
�C] 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 liepartment oL 1,0mmumLy LJevewpu►e,LL
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
< Revised 7/1/2011 Page 2 of 3
VA
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Intake to complete the following:
Reviewer to complete the following:
Y N.,
Square footage of Use:
Is u F LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y
Will e be food preparation?
/ N
"'Permitted as: &bAl
Under Section:
If so, give applicant a Health Department form.
Zoning review can not begin until we receive approval from Health
Supplementary regulations section:
Dept. FAX DATE
SP's:
If so,i ist:
Circle the one that a plies
Parking formula:
Is parcel on rivate well r public water?
If private well, prove e Health Department form.
Zoning review can not begin until we receive approval from Health
Required spaces:
Dept. FAX DATE
Y/N
Circle the one that applies
Is parcel o septi or public sewer?
Items to be verified in the field:
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Inspector : Date:
Y / N
Notes:
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Violations:
Y/
If so, List:
Proff rs:
Y /
If so, ist:
Variance:
If sooist:
SP's:
If so,i ist:
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3