HomeMy WebLinkAboutCLE201300268 Legacy Document 2014-05-08Application for Zonin Clearance�rEl�'`
CLE #
OFFICE USE ONLY
/
PLEASE REVIEW ALL 3 SHEETS
Check # Date:
Receipt # –g 33 y 2– Staff: JS
PARCEL INFORMATION
Tax Map and Parcel: L,) /Ca )o —O3i —o —oz Lpw Existing Zoning
Parcel Owner: ir�l� 17K�e _ �/�v 44(,,
Parcel Address: 2A6( 0. ,,/taPjWQv1n %w ;v o City C ,�/ l_I� State Zip 22 V
(include suite or floor)
PRIMARY CONTACT
Ay r+k
Who should we call /write concerning this project?
xx // /
ZY � i' C 14t:?ani 14-11 Y�. City GhA!'Co ���5 t �e. State
Address: ai2A
Office Phone: CZ 23� Cell # Fax # E -mail
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name /Type: QJ C2 �
Previous Business on this site
Describe the proposed business including use, number of employees, n ber 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
knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
is true and accurate to the best of my
Signature Printed
APPROVAL INFORMATION Denied
Approved as proposed [ ] Approved with conditions [ ]
[ ] Backflow prevention device and /or current test data needed for this site. Contact ACSA, 977 -4511, x117.
Therefore, it is not a determination of compliance with the existing
[ ] No physical site inspection has been done for this clearance.
site plan.
[ ] This site complies with the site plan as of this date.
Notes:
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Building Official.. �— Date
Zoning Official Date 2�l4
Other Official Date
County of Albemarle Department of Community Development
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:
/CM
Is us m LI, HI or PDIP zoning?
Engineer's Report (CER) packet.
If so, give applicant a Certified
Y /—!,
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
Circle the one that applies. Parking formula: n
Is parcel on private well ater?
If private well, provide ealth Depa ment form.
Zoning review can not be ' we receive approval from Health Required spaces:
Dept. FAX DATE
Reviewer to complete the following:
Square footage of Use; % (-) r
4/ N
Permitted as; rej� fli
Under Section: 2=�
Supplementary regulations section:
Circle the one that applies
Is parcel on septic or se er?
Y/N
Will you be putting up a new sign of any kind?
Sign permit.
Permit #
Y/ cow
Items to be verified in the field:
If so, obtain proper
Inspector : Date:
Notes:
Y/N
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Boning to cull!
Violations:
P s /N
o, List:
lute L11C lunvYYll1
11
Proff rs,
Y
If s , ist:
Variance:
6/N
If so, List: �9!j7
l
� i
SP's:
Y/N
If so, List:
Clearances:
SDP's J
Revised 7/1/2011 Page 3 of