HomeMy WebLinkAboutCLE201400131 Legacy Document 2014-07-17Application f ®r Zoning Clearance
� Y `�<
_
\ �RGIM'tPI
PLEASE REVIEW ALL 3 SHEETS
OFFICE USE ONLY
Check# x,45 Date:
Receipt # f 2S/ 3 Staff: /,
PARCEL INFORMATION
Tax Map and Parcel: Existing Zoning C.
Parcel Owner: L.6- G
Parcel Address: Z,70 ley R 4 S , I i 1 City Cyr `�/► tt -J d C State Zip -`Z ° \Q
(includ suite or floor)
PRIMARY CONTACT
Who should we call /write concerning this project?
Address : City State Zip
Office Phone: L_) Cell # Fax # E -mail
APPLICANT INFORMATION
Check any that apply: Change of ownership "C_ Change of use - Change of name New business
/
Business Name /Type: ��� I�l i fn G �A Lazes S c' e�� 6t : 11 C {S( av (IrA
Previous Business on this site 7 p., —z_, S Core Q
Describe the proposed business including use, number of employees, number of shifts, available parking spaces, number of
' (p
vehicles, and any additional formation that you can provide: �'� pl o yg6 - Z SI�A7'S
�no�, y,� {�.4,1`JC\1\ S �QaCQ
*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 o 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 tot best o my knowledge. I have read the conditions of approval, I understand them, and that I will abide by them.
,'and
Signature Printed �V i f 0 C "Cc� S
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 /
2�O
Zoning Official Date 1-7
,
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:
IsJSin Is LI, HI or PDIP zoning?
Engineer's Report (CER) packet.
D/N
If so, give applicant a Certified
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 o u lie ater?
If private well, provide He lth epa vent form.
Zoning review can not begin anti we receive approval from Health
Dept. FAX DATE
Circle the one that applies
Is parcel on septic o
Y / N -----
Will you be putting up a new sign of any kind?
Sign permit.
Permit #
If so, obtain proper
Y/N
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the following:
Reviewer to complete the following:
Square footage of Use:
0/N
Permitted as:
Under Section:y Z
Supplementary regulations section:
Parking formula:
Required spaces:
Y /"N
Item o be verified in the field:
Inspector • Date:
Notes: 1 )
Violations:
Y/N
If so, List:
Proffers:
Y/N
If so, List:
Variance:
Y/N
If so, List:
SP's:
Y/N
If so, List:
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3