HomeMy WebLinkAboutCLE201300294 Legacy Document 2014-06-03Application for Zonin Clearance
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PLEASE REVIEW ALL 3 SHEETS
OFFICE USE ON Y
Check # Date:
Receipt # ( Staff:
PARCEL INFORMATION
' ' yq R 6 D Zoning
Tax Map and Parcel: ���Q U ' (� Existing
Parcel Owner: -1-4 ��1/� � 1LCII
%1. &(Ifyd L State y Zip
Parcel Address: l City
(include suite or floor) �a
PRIMARY CONTACT `��� - C
V
Who should we /gall /write concerning this project?
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�0 r�'l �t/ ^ State Zip
Address :_t 1 _City _
Office Phone: U Cell# S �JI"�1Gj' x # E -mail 3�
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name /Type: �1� G 7
Previous Business on this site na
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 o the best of my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
G& Signature Printed _ V� 6U-rT-TA
AP OVAL 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 J— 1
Zoning Official Date
Other Official Date
County of Albemarle vepartment of Commumry meveiopmeut
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
Revised 7/1/2011 Page 2 of 3
L p.
Intake to complete the following:
Y/N
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y (N)
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 applies
Is parcel on private well or public water?
If private well, provide Heal a me form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applies
Is parcel on septic or public sewer?
V Y/N
ill you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit # LA -Tt— -
/N
ill there be any new construction or renovations?
If obtain he ro x Permit.
Permit # 0 A-C-)
Reviewer to complete the following• J
ac -Pico ply
Square footage of Use:
Y)/ N
Permitted as: q
Under Section:` #nn
JK@J�r �M
Parking formulA: //a
Required spaces: - - - -
Y/N
Items to be verified in the field:
Inspector Date:
Notes:
/JUn Jar, V �U. E 1V4V i11V 1
Viol s:
Y/
If so," 1st:
P ffers:
/N
so, List:
Variance:
Y /�l�is
If s t:
SP's•
Y / N
If s ' ist:
Clearances:
SDP's .-- I®
Revised 7/1/2011 Page 3 of 3