HomeMy WebLinkAboutCLE201200073 Legacy Document 2012-05-015, 1 ff, AM, 0
Application for Zoning Clearance`
�;t'
CLE # 212. - q.5
;
'' : :: ,..err
OFFICE US O ,�
4-2-12
PLEASE REVIEW ALL 3 SHEETS
Check# Date:
Receipt # , ' W f Staff: Y`(1 V,
PARCEL INFORMATION n
Tax Map and Parcel: 3 % '' LP (�� 1 / 40 a_e VLS) Existing Zoning po / N
Parcel Owner: —\/A- 1' % 0 wJDA-r/ Pt
Parcel Address: rW 15, + C-AV V_ DLo l VC, City ii4Kf"-rTW49tate Or Zip 2?o
(include suite or floor)
PRIMARY CONTACT '
Who should we call /write concerning this project? �� > Qcit-i uPqN
Address: I jJC WP 2 RFAD Pb1 PJfit-� City C D1154yl LState Vp� Zip 2�0
Office Phone: &J 9z4 viol)(( Cell # Fax # / `'`t fiJZ E -mail 4V=�J0P Vi M (ni4 .eJiU-
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name /Type: -4 k e, W O U VIeW Cam" �'— JW� Z 2,01 Z...
`
UM t6t Olk Pa'V V—
Pr,QacietrsBusiness on this site K- -O-V
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 accur to the best of woeowl e. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature Printed D&O 1��1� VA k L—e"'a'G
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
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
Intake to complete the following:
v/ N
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y/0
Will there be food preparation?
If so, give applicant a Health Department form.
Zoning review can not begin until we receive approval fi•om Health
Dept. FAX DATE
Circle the one that applies
Is parcel on private well or public water?
If private well, provide Health Department forin.
Zoning review can not begin until we receive approval fi•om Health
Dept. FAX DATE
Circle the one that applies
Is parcel on septic or public sewer?
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y/®
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
7,nninu to eomnlete the following:
Reviewer to complete the following:
Square footage of Use:
N �j...
Permitted as:
Under Section:
Supplementary regulations section:
Parking formula:
Required spaces:
Y/N
Items to be verified in the field:
Inspector : Date:
Notes:
Violations:
Y/N
If so, List:
Proffers:
Y /N.
If so, List:
Variance:
Y/N
If so, List:
SP's:
Y/N
If so, List:
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3