HomeMy WebLinkAboutCLE201200046 Legacy Document 2012-03-09Application for Zon • Clearances
CLE # �(� 1 � m
4M
PLEASE REVIEW ALL 3 SHEETS
OFFICE USE ONLY �� J� ! ✓�
Check # Date:
Receipt # Staff: J/r U�L iII
PARCEL INFORMATION � � 2 J Existing Zoning ed
Tax Map and Parcel: X71 Z+onC a nl
Parcel Owner: I/ v J Y ` t'" '"' ( O 1 J� d U 1 v
Parcel Address: v, W City l i /v State ? 1 Zip
(include suite or floor)
PRIMARY CONTACT 9 G_ �Un � t �2
Who should we call/write concerning this project.
Address: 3 J Cit} C, Q Ps11- ate V 17 Zip p
Of .cePhone: ('3 2�3�Z70 jCell# Fax# ,Inaii
APPLICANT INFORMATION
Check any that apply: Change of ownership. Change of use Change of name New business
p ^/
Business Name /Type:
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 accurate to the best of knowledge. I have read the condit' s of approval, and I understand them, and that I will abide by them.
Signature Printed (JVt
APPROVAL INIFORMATION
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
Zoning Official Date
Other Official Date
County of Albemarle 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
62
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Intake to complete the following:
Y /
a
Is us in LI, HI or PDIP zoning?
Engineer's Report (CER) packet.
If so, give applicant a Certified
Y ehere Wil 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 ublic water.
If private well, provide Health ep ent 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 Iic sewer,
Y /%N
Wi ou be p' utt b nTp a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y/9
Will there be any new construction or renovations?
If so, obtain the proper Permit. "
Permit #
Znnin¢ to complete the following:
Reviewer to complete the following:
Square footage of Use:
al
Permitted as:
Under-Section: .Z 2-
Supplementary regulations section:
Parking formula:
Required spaces:
Y/
Items to be verified in the field:
Inspector : Date:
Notes:
Violations:
If Y S /Opist:
Proff s:
Y/
If so, ist:
Varignce:
If o`�,ist:
If s/o,LList:
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3