HomeMy WebLinkAboutCLE201200106 Legacy Document 2012-05-23Application for Zoning Clearance
CLE # 2212.
. �.
' .�,, �A'lJ"T
PLEASE REVIEW ALL 3 SHEETS
OFFICE
Check# Date:
Receipt # Staff: rVYKC .)
PARCEL INFORMATIO /qmaip /i r�
Tax Map and Parcel: l J "I Existing Zoning bJ
Parcel Owner: MULE PJ�
Parcel Address: CityrG� !I State Zi_�!„
(include suite or floor)
PRIMARY CONTACT
Who should we call /write concerning this project?
Address : / City J State Zi
Office Phone& 'G� ell # �/ / / Fax # E -mail 0110 j
APPLICANT INFORMATION
Check any that apply: Change of ownership� Change of use _Change of name New business
�— j
Business Name /Typel(11�i OE dw 1 �JLA TTdQ i- ArK)
Previous Business on this site
Describe the proposed business including use, number of employees, number f shifts, available parking spaces, number of
vehicles, and any additional information that you can provide: e `�
*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 th owner's permission to use the space indicated on this application. I also certify that the information provided
is true d ac to to the be t of m knowledge. I have read the conditions of approval, and I understand them, and that I will
Signature Printedd' IvRt�
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���7
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:
Y/6
Is use in LI, HI or PDIP zoning?
Engineer's Report (CER) packet.
�M
If so, give applicant a Certified
Will 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 povTTe ll or public water?
If private well, ide 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 tutor public sewer?
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 #
Zoning to comDlete the followiner:
Reviewer to complete the following:
Square footage of Use:
Cpl
as:
Under Section:. J h
Supplementary regulations section:
Parking formula:
Required spaces:
Y/N
Items to be verified in the field:
Inspector : Date:
Notes:
Violati ns:
Y /(I
If so, List:
Proffers:
Y/
If so6ist:
Variance:
Y /�
If so, ist:
SP's:
Y pist:
Ifs
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3