HomeMy WebLinkAboutCLE201300235 Legacy Document 2013-10-04Application for Zoning ClearanceE��`'
pF Al,ll
CLE #����
}d
OFFICE US Y
PLEASE REVIEW ALL 3 SHEETS
Check # Date: `
Receipt # Staff:
PARCEL INFORMATION
Tax Map and Parcel: fir/ ` �2_ Existing Zoning
l3
Parcel Owner: CiAl') J /
p �1
Parcel Address: ��� to �,>, ?J '�, city �dl ► //I ��• State Zip
(include suite or floor)
PRIMARY CONTACT �/ f I
5co -R "
Who should we call /write concerning this project? / ,.,,1 t
6k_"_,1 J0 FC-rW. 1b City C(/(�� ^lv' su�ll�,State V Zip 22p�
Address:
Office Phone: J-5 -U Cell # s31 Fax # E -mail
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name /Type: 3t ow"l
Previous Business on this site
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:
*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 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 Printed
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 PO ( 2
Zoning Official Date
Other Official Date
County OI Alnemarle 1JeparLme116 01 %_.vu1111uuu.y UV V Up■i!o!A
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 us n LI HI or PDIP zoning
If so give applicant a Certified
Reviewer to complete the following:
Square footage of Use:
Engineer's Report (CER) packet. (� / N
ermitted as:y
Y/
Will Were be food preparation? Under Section: Q &A,
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
Circle the one that applies
Is parcel on private well or p "Ile wa el
If private well, provide Health partment form.
Zoning review can not begin until we receive approval from Health
Dept, FAX DATE
Circle the one that appjis
Is parcel on septic or p blic sewer.
Y/N
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 #
+hn fnllnwina-
Parking formula:
Required spaces:
Y /!N
Items to be verified in the field:
Inspector:
Notes:
Date:
uvas...
Viola ions:
Y/
If so, List:
Proffers:
Y /lam
If so, List:
Variance:
O/N
If so, List:
SP's:
Y/
If so, ist:
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3
0
ca