HomeMy WebLinkAboutCLE200700258 Legacy Document 2014-04-28Application for
t4`, Zonin Clearance
OFFICE SE ,
Zoning Clearance = $35 CLE #
PLEASE REVIEW ALL 3 SHEETS Check # Date:
Receipt # Staff: tJ��
PARCEL INFORMATION
QQ
Tax Map and Parcel: � NG Q(Ol � 4�' Existing Zoning AID
Parcel Owner:
Parcel Address: q` -) 616Nwoop STAT1oo /_A) Sri
(include suite or floor)
03
7 64Aal- 61155V1UU5 State yil Zip ZZ1701
PRIMARY CONTACT /
Who should we call/write concerning this project? A 16vj
Address : 126Y A✓WN PSee, 51?5el� City ejAeCo1r-65sv1u.E State yt Zip
Office Phone: ( la 1 9 Cell # Fax # Z3�5 E -mail f'IICD�¢ o uivlka �25 L63 L�-
TION �
Business
APPLICANT
Name/Typ FORMA flw2rd 15 Ey ,i✓D4l67.0,4Z 5 cc ?l. ants
Previou'sBusiness on this site AAA i9J &A 0 aA46 �6QiLr
Wicribe'the proposed business, including use, number of employees, number of shifts, available parking spaces andany
additional information that you can provide: QLe w eCL Ce h$k•/ 4 5ewi 4v 4& (h1,US&Aj /actnd✓y
.f , J. . cu:LA.._ -0 . _ - -/—._ it ?i_ -1... . ...... ...... ...._.- -- . . . _ ..
*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 m owledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature Printed N/eD6e P. - AAJ,,nSNK,e—
AP`jrROVAL INFORMATION
[ proved as proposed [ ] Approved with conditions [ ] Denied
ackflow prevention device and/or current test data needed for this site. Contact ACSA, 977 -4511, x119.
[V]'flo 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......1� -
Zoning Official ; l::. . • Date
Other'Ot iciaf, Date
UOUnly OI Alpemarle juepartmeni oI t- omintu nLy "rVC1UPU1VI1L
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fag: (434) 972 -4126
5/1/06 Page 2 of 3
Intake to complete the following:
❑ YES [9"! O
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
❑ YES NO
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
❑ YES ❑ NO
Is parcel on private well orLublic water?
If private well, provide Health rep- Mrient form.
Reviewer to complete the following:
Square footage of Use: '31-79
�YES ❑ O ( n
Permitted as: h6
Under Section:
Supplementary reddlations section:
Parking formula: 6 AZFa
Zoning review can not begin until we receive approval from Health Required spaces:
Dept. FAX DATE (, i
❑ YES ❑ NO
❑ YES ❑ NO
Is parcel on septic or public sewer?
❑ YES 2/NO �^
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
❑ YES [D/NO
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Items to be verified in the field:
Inspector : Date:
Notes:
Gorilri -i'ecn to pompiete the tonowin :
Violations: Pro fers:
❑ YES F1 NO YES ❑ NO
If so, List: If so, List:
Variance: SP' :
❑ YES NO YES ❑ NO
If so, List: If so, List:
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