HomeMy WebLinkAboutCLE201200003 Legacy Document 2012-02-0150. 00
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Application for Zoning Clearance
CLE # Z b 17 - 3
PLEASE REVIEW ALL 3 SHEETS
OFFICE i1 � O LY
Check # pate.,
Receipt #W Staff: �rylAn r_,
PARCEL INFORIVIATION 5 d0 ,
�d d�'l6&Ifd
Tax Map and Parcel: Existing zoning
Parcel Owner: �L& -
Parcel Address: 0\2' aq=b� 0l \ \_67 c � _ Cit �c ,oy �\ State \P A- Z9p2�1��
(include suite or floor)
PRIMARY CONTACT p
Who /write L L�
should we cal] concerning this project?�v` i
Address: City State Zip
Office Phone: (�n92 it,}�t( Cell # Fn `- #� -� [ E -mail
APPLICANT INFORMATION
Check Any that apply: =change of ownership Change of use Change of name New business
Business Name/Type : "MV�, a� Z g'
Previous Business on this site \ �'� (A` _
-Describe the proposed business including use, number of employees, number of shifts, available parldng 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 anew 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 th��,,_?.i<oe -my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature K c "�`%- `� Printed A,���`��.�
APPROVAL INFORMATION
Approved as proposed [ J Approved with conditions [ 'j Denied
j Bacicflow prevention device and /or current test data needed for this site. Contact ACSA, 977 -4511, xi 17.
[']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 It
Zoning Officia) . i Date
Other Official -- !` � ate l A ,�.0 2-!
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voices (434) 296 -5832 Fax: (434) 972 -4126
Revised 7/1/2011 Page 2 of 3
Intake to complete the following:
Y N
Is W in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
V Y/N
ill 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 p blic water
If private well, provide Health epa en orm.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applies___ --
Is parcel on septic or ub1ic sewer
0!-��ube putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y /
Wil ' e 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: GGIA � j c O Q` ((�� 6 (,11/UC',✓, f I j
N
'P'ermitted as: k11111 ¢ `
Under Section: -Z L), Z, )
Supplementary regulations section:
Parking formula: f j
dO J
Required spaces:
Y/
Items to be verified in the field:
Inspector:
Notes:
Date:
Violations:
Y/ (�D
If so, List:
Proffers:
Y /i')
If so,rist:
Varia ce:
Y /
If so, List:
SP's:.
Y /
If so, ist:
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3