HomeMy WebLinkAboutCLE201200100 Legacy Document 2012-06-07Application for Zoning Clearance
• -tyy --
"tt?pS1C�1
OFFICE llS L�'
PLEASE REVIEW ALL 3 SHE
Check # Date:
Receipt # Staff:
PARCEL INFORMATION
Tax Map and Parcel: CAA 0().200 Existing Zoning
Parcel Owner: u t r' l-[aty
Parcel Address: I I q Sem iA.)oV_' l K �.. City 044e g(3tlt 11e State VA Zip s `%��
(include suite or floor)
PRIMARY CONTACT
Who should we call /write concerning this project? J)AAJ
Address: IS-() NMeAwwae o < LA-)—city B l -eeyy; l k State VA,
Office Phone: 703 q2 7 - a'7 ( 9 Cell # -5,1110f- Fox # E-mail
APPLIC ANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name/Type: 6eASrNA)S OF CH.A/ Y6E IR4c& A6wS'7' Deucros
Previous Business on this site C k k'eL0fSQ & P0WE0— Ewl DMear
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: t elti4 A LC Oft (66 A WKLY L
f=Uev 10Ee_<, Z 1,_ Ty) V7,, Z o l a
*This Clearance will only be valid on the parcel for which it is approved. Ifyou change, intensify or move the use to anew 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 infornu lon provided
is true and accurate to the bet of my knowledge. I have read the conditions of approval, I understand them, and that I will abide by them.
,and
Signa Printed , c- fa.
APPROVAL INFORMATION
[ j Approved as proposed [ ] Approved with conditions [ ] Denied
[ j Backflow prevention device and /or current test data needed for this site. Contact ACSA, 977 -4511, x117.
[ j No physical site inspection has been done forthis 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,
;Votes:
Building Official Date
Zoning Official Date 6 I/ 4J) �
Other Official Date
County of Albemarle .Department of community ipeveiopment
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
Revised 711 /2011 Page 2 of 3
Intake to complete the
Y /(_',
Is ust4LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y /
WiI re be food preparation?
ff 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 or ublir wat ?
If private well, provide Hea lent form.
Zoning review can not begin until we receive approval from Health
Dept, FAX DATE
Circle the one that ap
fs parcel on septic or es
Y/N
Wilk 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 obtain the proper Permit,
Permit i#
7 ' to com let. the foilowin
Reviewer to complete the following: .
Square footage of Use:
:2-o O
/N
ermitted as: _7111110-5
Under Section; ea-,221'A ?✓Rcil i
Supplementary regulations section:
Parking formula:
Required spaces:
Y/N
Items to be verified in the field:
Inspector: Date:
Notes:
onin
Violations:
,�ID/ N
If so, List: ) n
Proffers:
Y /
If so, List:
Varia Ce:
Y
If so, List:
SP "s:
Y/QD.
If so, List:
Clen rances:
;SDP's
Revised 7/1/2011 Page 3 of