HomeMy WebLinkAboutCLE201400164 Legacy Document 2014-08-271M� Cox w1) I P_1MQi') you -�k
Application f ®r Zoning Clearance
0
PLEASE REVIEW ALL 3 SHEETS
OFFICE USE ONLY
Check # ej S� Date:
Receipt # Q Staff:
PARCEL INFORMATION
Tax Map and Parcel: Existing Zoning
Parcel Owner :Q
Parcel Address: 470 1 V`e e,_, State
(include suite or floor)
PRIMARY CONTACT
Who should we call /write concerning this project? -b
Address: l onc) 6Le� l) ax qt u, City cl i ate Zip 22,:R I
Office Phone: �J _3 �Ce11 #�Q�� pt}bj Fax # E -mail (-I
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use AV_Change of name New business
t�1
Business Name /Type:`'le
Previous Business on this site
Describe the proposed business including use, number of employees, numbejQf shifts, available parz0 g spaces, number of
vehicles, and any additional information that you can provide: iMlreSS V
*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 acc he best of my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature - Printed
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 of 6�;P
Zoning Official Date
Other Official Date
County of Albemarle Department of Community vevelopment
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:
Y/N
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
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
Is parcel on private well o public :wa:ter?)
If private well, provide Hea rm.
Zon ing review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applies
Is parcel on septic or lic sewer?
Y Q
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y /
Wil ere be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
7.nnlnn fn (- mmnlPiP thp fnllnwlnu!
Reviewer to complete the following:
Square footage of Use:
A / N
mitted as: ✓P�"fl�
Under Section:
Supplementary regulations section:
Parking formula:
Required spaces:
Y/
Items to be verified in the field:
Inspector : Date:
Notes:
Violations:
[9 / N
If so, List: � �
Proffers:
Y / (9
If so, List:
Varian e:
Y /It)
If so, List:
SP's:
Ll?)/N
If so, List:
o S 3s
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3