HomeMy WebLinkAboutCLE201300236 Legacy Document 2013-10-04Application for Zoning Clearance
PLEASE REVIEW ALL 3 SHEETS
OFFICE U )nVLY
Check # l Date:
Receipt # Staff:
PARCEL INFORMAT v
Tax Map and Parcel: °(�� Existing Zoning
Parcel Owner: �ytiy a, V i G� 0
Parcl'Q ress: — Ft) �44 ee City State Zip
(include suite or floor)
PRIMARY CONTACT a
'
Who should we call /write concerning this project? � '{����N Q A
1
`� � ��t'lV l' �% • City State V t� Zip�%J�
Address: A
Office Phone: Z`ll 1 3�1Cell # Fax #
7�1
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name /Type: Vll al. C 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 y knowle e. I have read the conditions of approval, and I understand I will abide by them. .
0th�e fm,/a'n/ddtthaat
Printed
Signature
APPROVAL INFO ATION
Approved as proposed [ ] Approved with conditions [ ] Denied
[ ] Backflow prevention device and /or current test data needed for this site. Contact ACSA,977- 451,1, 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 OI Albemarle ueparLment O1 L,U1luuuuny jUVVrJvNuwlu
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 /I&
Is use in LI, HI or PDIP zoning?
Engineer's Report (CER) packet.
If so, give applicant a Certified
Y /I�
Will 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
Circle the one that pplies
Is parcel on p ' a e ell or public water?
If private well, vide 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 e' tic r public sewer?
Y /i
Wil 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 #
Z ' t om lete the followin
Reviewer to complete the following:
Square footage of Use:
6/N
-
Permitted as: L�-� (A � fro -17
Under Section:' 1 ,3 •'L
Supplementary regulations section:
Parking formula:
Required spaces:
Y
Item / be verified in the field:
Inspector : Date:
Notes:
onm o c
Violations:
Y/
If so"—, fist:
Proffers:
Y/
If so, ist:
Varia ce:
Y /(N�
If so, List:
SP's:
/ N
if so, List:
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3