HomeMy WebLinkAboutCLE201200256 Legacy Document 2014-10-300
Application for Zoning Clearance
CLE # 2-5
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PLEASE REVIEW ALL 3 SHEETS
OFFICE USE ONLY
Check # 11065 Date: 2
/
Receipt# �/?J Staff:
PARCEL INFORMATION
Tax Map and Parcel: --t0 Existing Zoning
Parcel Owner: VIA51V IO P#t/s rGJxl �r
Parcel Address: 500 t�iihj �', ��,Jf. city ,I*OLo�V OI ; State Zip 1i3
(include suite or floor)
PRIMARY CONTACT
AZ a &r&
Who should call /write concerning this project? A
�wee
Address: 5�0 ®(?'1 City f'�Q(VV State n Zip7XD
Office Phone: �} Cell # 3 ' 5 '7 Fax # E-mail AT_
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name /Type: ja
4--
Previous Business on this site
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 accurst o the best of my knowledge. I have read the conditions of hpproval, and I understand them, and that I will abide by them.
L1
Signature Printed
014L,W REP,
APP INFORMATION
[ . pproved as proposed [ ] Approved with conditions [ ]Denied
[ ] Backflow prevention device and /or current test data nee4ed 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 his date.
Notes: i ; * rtYy�1, 11A 11,11 sA ji r Q , 04
Building Official Date -
Zoning Official - YvAIVY'l &W& Date 12.
'e–
Other Official Date
l.;ounLy 01 Aln UMUrle VCP2t1- L11[C11L v1 t..va1tuLLL11 %Y yc T a.avl.r.aaa•.a..
401 McIntire Road Charlottesville, VA 22902 Volbel., (434) 296 -5832 Fax: (434) 972 -4126
w 1. Revised 7/1 /2011 Page 2 of 3
9
Intake to complete the following:
Y /
Reviewer to complete the following:
Square footage of User
Is usPILI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
•Z' N
Permitted as: 01 Iq
�Nt,ere be food preparation?
� . , I ,
Under Section: _
If so, give applicant a Health Department form.
Zoning review can not�bLeZin until�v receiv approval from Health
_1�'
Supplementary regulations section:
I �G
Dept. FAX DATE ( D_
SP'
N
Ifs , ist:
Circle the one that applies
Parking formula: 1116
Is parcel on private well or ublic water?
If private well, provide Hea form.
_, v P
Zoning review can not begin un it we receive approval from Health
Required spaces:
Dept. FAX DATE
Clearances:
Y/N
Circle the one that appli
Items to be verified in the fiel
Is parcel on septic or
@ill N
you be putting up a new sign of any kind? If so, gbtain proper
Sign permit. d2 j 1, ,
Permit # IJ j�fAIULI.
%
Inspector : Llkc �/Y Date: O � l h
Y N
Notes:
ill there be any new construction or renovations?
If so, obtai the rope ermit.
Permit # JOI (� LIL/
v
Z nin to com late the followin
0
Vio hO :
Y /�N%
Ifs moist:
Pro
Y/
Ifs ist:
Vari
Y/ INI
If s ` ist:
SP'
N
Ifs , ist:
Clearances:
SDI's.
Revised 7/1/2011 Page 3 of 3