HomeMy WebLinkAboutCLE201300255 Legacy Document 2013-11-07Application for Zoning Clearance'`
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OFFICE USE ONLY
PLEASE REVIEW ALL 3 SHEETS
Check #
Receipt # Staff:
PARCEL INFORMATION
Tax Map and P rcel: Existing Zoning
1
Parcel Owner. S
Parcel Address: Sgvctivt VA n}Ll-•- City State zip 2z`y 1
(include suite or floor) '
PRIMARY CONTACT
_
Who should we call /write concerning this project? beivIA
Address: Let -7 Vickoy -%Ayl C-k City e V A`f State i% tA— Zips
Office Phone: 6YAJ y 47- -7b (aJ�- Cell # Fax # E -mail ti.P_ CC) M Ctc!.J"- tAV
APPLICANT INFORMATION
Check any that apply: of ownership Change of use Change of name New business
Change
Business Name /Type:
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 � s 5 r , Printed �A-V k j
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, xl 17.
[ ] 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 f 1 1 3
Zoning Official Date
Other Official Date
County of Albemarle Department or %,ommurriLy .,CVC,uN111o■1L
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 n LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y N
Will ere 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
Reviewer to complete the following:
Square footage of Use:
(9/N
Permitted as: i^ ��
=I P ✓I
Under Section: - f m . -- -1 t ; s�
Supplementary regulations section:
Circle the one that applies
rarxmg rormuia:
Is parcel on private well o6-- lic .
If private well, provide Health Department form.
Zoning review can not begin until we receive approval from Health
Required spaces:
Dept. FAX DATE
Var' ce:
Y N
If so, IN
Y/
Circle the one that applies
Item be verified in the field:
Is parcel on septic o uli is se— sewer--,:,'
Y/N
Clearances:
ill you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Inspector : Date:
Permit #
I, N
Notes:
Will ere be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Z ' to com late the followin
onm
Violations:
Ifs /d;-eist:
Proffers:
Y /
•Ifs O st:
Var' ce:
Y N
If so, IN
SP's:
Y/N
Ifs
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3