HomeMy WebLinkAboutCLE201400143 Legacy Document 2014-07-28Application for Zoning in Clearance,
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CLE # ZO )
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PLEASE REVIEW ALL 3 SHEETS
OFFICE USE ONLY
Check # C5 -s Date: -Zl
Receipt # &T Staff:
PARCEL INFORM, TI,O&_ > �J j�
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Tax Map and Parcel: ' �i 2— / �C' - !� 7 Existing Zoning �/
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Parcel Owner: � %2 S� / � ,
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171X) ?Jkity C ?-d State V Zip 2;
Parcel Address:,S-735
(include suite or floor)
PRIMARY CONTACT � � SS � �
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Who should we call/write concernng this project. �_
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Address : ,()�
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Office Phone: C__) Cel( dB Z� F® # E- mail ��d�
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
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Business Name /Type:
Previous Business on this site 7,9
Describe the proposed business including use, number of employees, number of shifts, available parking spaces, number of
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vehicles, and any additional informgtion 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, a d I understand them, and that I will abide by them.
Signature � k-) P I I Q-S: S Printed
APPRO VAX INFORMAT TO N
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:
<— Date��_
Building Official
Zoning Official Date
Other Official Date
County otAlbemarle iiepartment of q.omnrwuLy LCVCiUNnioiaL
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
Revised 7/1/2011 Page 2 of 3
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Intake to complete the following:
Y/N
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engin is Report (CER) packet.
Y/
Will Ure 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 ubli�ent
If private well, provide He form.
Zo ning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that ap ' s
Is--parcel on septic o public sewer?
Will N
l you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y/N
Will e be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
7nninu to cmmplete the following:
Reviewer to complete the following:
Square footage of Use: 5 00
Y/N
Permitted as: Xe.A,4, V �n
Under Section: 2 U
Supplementary regulations section:
Parking formula:
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1)
Required spaces:
Yf
Items to be verified in the field:
Inspector : Date:
Notes:
Violations:
Y/
If sliist:
Proff rs:
YIN
If so, ist:
Varia e:
Y/
If so, List:
91s:
/N
If so, List:
�7 —Z's'
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3