HomeMy WebLinkAboutCLE201200018 Legacy Document 2012-02-06R
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Application for Zoning Clearance
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CLE # 2��
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OFS'IGE USE OILY
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PLEASE REVIEW ALL 3 SHEETS
Check # I Date;
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Receipt # . Staff;
PARCE L INFORMATION „� n
Tax Ma and Parcel: (1 1 I Existing Zottini?
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Parcel Owner; P aa
Parcel Address; City State Zip
(include suite or oor) t
PRIMARY CONTACT
Who should we call/write concerning this pt jest?
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Address; V City state _ V f/ Zip
Office Phone: ( 4ell # 2 , x #! E-mail
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APPLICANT INFORMA "ION
Check any that apply; Change of ownership Change of use Change of name New business
/Type, es� '/a- uI l
Business Name
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Previous Business on this site 1 r 9
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 cettify that 1 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 kno�ledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature �i �—� �-- 'Z. Printed /1 1�fW fit," n
APPROVAL INFORMATION
Approved as proposed [ ] Approved with conditions [ ) Denied
[ ] Backflow prevention device and/or current test data needed for this site. Contact ACSA, 9774511, xl 17.
[ J No physical site inspection has been done for. this clearance. Therefore, it is not a detennination of compliance with the existing
site plan.
( ) This site complies with the site plan as of this date.
Notes,
Building Official Date I
Zoning Official Date ^4� —�/ Z/
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Other Official. „� l� a� �1� S1_4� �encvt�n �r�� Date t 2,1112
County of Aibemarlc 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:
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Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
( Y�/ N
dill there be food preparation?
If so, give applicant a Health Department form.
Zoning review can not begin until we receive approval from Health
Dept. FAXDATE /A / /Z01'—
Circle the one that applies
Is parcel on private well or ubli r?
If private well, provide 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 septic or u lic se ?
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y/N
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
7nniner fn e-mmlnlPfP fbe f6llowin4'
Reviewer to complete the following:
Square footage of Use: f ,� a 0
(9 /N
Permitted as: 4L4- ;,n4,
Under Section: 4 L l
Supplementary regulations section:
Parking formula: /3 _ 1
Required spaces: r D
Y /•
lte&4 be verified in the field:
Inspector: Date:
Notes:
Violations:
0/N
If so, List:
P offers:
-Y /N
so, List:
Varia ce:
Y/F
If so, List:
SP's:
(Y)/N
If so, List:
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3
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