HomeMy WebLinkAboutCLE201200092 Legacy Document 2012-05-30Application for Zoning Clearance
CLE # Lb 12 - q� �
OFFICE US ONLY
PLEASE REVIEW ALL 3 SHEETS Check# Date: • Z-4' 1Z
Receipt # 13Ldaaa Staff:
PARCEL INFORMATION
Tax Map and Parcel: D 1 OLO Existing Zoning
Parcel Owner: f�-�1� ►'1't I �. w. L- . �. (3� 1�l-1
Parcel Address; %LA Lt'�L S vc ,. �� ' (r City C A,' J, State c Zip 7-Z--9
(include suite or floor)
PRIMARY CONTACT
Who should we call /write concerning this project? L Y'. st-
Address : [ G G ( lxj,,,n�_,o 12 j City f 6 j uj ; J.- State _ 1, /.. Zip Z N?
Office Phone: (_� Cell # Fax # E -mail
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
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 o, 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 best of my knowledge. I have read the conditions of approval, and I understand then, and that I will abide by them.
Signature Printed ( .t,Q
APPROVAL INFORMATION
�t] 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 ibis 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 �S 1
Zoning Official Date
Other Official Date Z-
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:
Is Ve n LI, HI or PDIP zoning?
Engineer's Report (CER) packet.
If so, give applicant a Certified
Y /
Will ere 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 ="er't If private well, provide H n form.
Zoning review can not begin until we receive approval from Health.
Dept, FAX DATE
Circle the one that a
Is parcel on septic o ublic s
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 complete the followinLY:
Reviewer to complete the following:
Square footage of Use:
Y/N
Permitted as: 5a,4 Sb &,r/ 2a �Q
Under Section: 4M- 12tH
Supplementary regulations section:
Parking formula:
Required spaces:
Y/
Items to be verified in the field:
Inspector : Date:
Notes:
Violations:
&/N
If so, List:
Proffers:
Y/TA
I£so; List:
Varia e:
Y /F2
If so, List:
SP's:
/N
If so, List:
i3 =?j
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3
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