HomeMy WebLinkAboutCLE201300230 Legacy Document 2013-10-17Application for Zoni n Clearance
0
OFFICE U O LY ��,,``
Date: cl '2b °13
PLEASE REVIEW ALL 3 SHEETS
Check #
Receipt # Staff: Y1Jf
PARCEL INFORMATION /' �� V /� rw
Tax Map and Parcel: 4 `'t Existing Zoning f�✓
Parcel Owner:
Parcel Address: l,'% D�� �C'IYl �f1�1 t' City �1"CA('� 11�dU��l� State 1�GV Zip
(include suite or floor)
PRIMARY CONTACT
Who should we call /write concerning this project? ✓ C� n i�t 1`` r x-' e 6 S ���
City � 6409&Address ��o Se m��� e y ° lG State Zip 2.2�7Q
Office Phone: ( Cl - ell h(Sl 6 )e 3 54 6 x# E -mail
i
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use ChangeLof name New business
f-
Business Name /Type: ���5 ism i t5
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: K0 eJm n� �% S� S L y e � k lz f e I
I
*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 urate to 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 k)Q(1 l �-P Ci P�,�C1Y 1
g
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 b xx [! -2,
Zoning Official Date , 3
Other Official Date
County of Atpemarle iiepar[meni or k.omrnuri1ty Mt:VV1UVJ11UA1
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 u i LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y /Nl
Wil here 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 will ublic water
If private wall, provide Healt ment form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that
Is parcel on septic o ublic sewer.
Y/N
Will you be putting up a new sign of any kind?
Sign permit.
Permit #
Reviewer to complete the following:
Square footage of Use: /O 6 (i
Permitted as: _ �e ��v c—
Under Section: X5.2
Supplementary regulations section:
Parking formula:
U
Required spaces:
Y/
Items to be verified in the field:
If so, obtain proper
Inspector : Date:
Y N Notes:
Wi t re be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Vnnin[s 4n emmnlPfP fhp fnllnwlnu:
Violations:
y_/ ,
If s t:
Prof s:
Y /N�
If so, List:
Variance:
Y /1 I�
l
If so, ist:
SP's:
Y /
If so, ist:
Clearances:
SDP's
Revised 7/1/201.1 Page 3 of 3
? , n o
G