HomeMy WebLinkAboutCLE201500098 Application 2015-05-22Application for Zonin Clearance
Is—
CLEW , —5
PLEASE REVIEW ALL 3 SHEETS
OFFICEUSE ONLY
Cheelc #IC — Date:
Receipt # "t` l 5 l `� Staff: _ Z
PARCEL INFORMATION
Zonin
Tax Map and Parcel: C�'� 9bb ivxistin g g
14-
Parcel Owner: .�LJOXMI
Parcel Address:�r'0 City �r�p1j/'�� 1, State Zip�',�
(include su e o - floor)
PRIMARY CONTACT // (
Who should we call/write concerning this project? LO tJi rLhnV-711
s LL City : G State Y iq Zip
Address: ��i.l^'► + 1, h kv�
Office Phone: = Cell # 82?4-XJ3.3.JJS Fax # g�!S40-`/Q E-mail
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APPLICANT INFORMATION
Check any that apply. ,, Change of ownership Change of use Change of name New business
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Business Name/Type:
Previous Business on this site J " -
Describe the proposed business including use, number of employees, number of shifts, available parking spaces, number of
vehicles, and ny additional information that you can provide ;, �,�rJ rte_ ,yy Ae S
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*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 be knowledge. I have read the conditions of approval,' and ti►em, and that I will abide by them.
/Ijunderstand
Signature Printed,���+�+t
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. • I
[ ] This site complies with the site plan as of this date.
Notes:
Building Official Date
Zoning Official Date
Other Official Date
County 01 Aipemarie meparLmen[ 0I %-uLnmunuy j--v-up1xA-x-
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
/s6 ➢4'
Is usi LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y/
Willit 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 wello pub ' ater?
If private well, provide Hea ment form.
Zoning review can not begin until we receive approval from Health
Dept, FAX DATE
Circle the one that
Is parcel on septic or public se er
/N
ill you be putting up a new sign of any kind?
Sign permit.
Permit #
If so, obtain proper
Y/N
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
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Reviewer to complete the following:
Square footage of Use: 2 y,
Y / N. I
Permitted as: ✓ Z+', i
Under Section: Z Sh 2—
Supplementary
Supplementary regulations section:
Parking formula:, C
v
Required spaces:
Y/N
Items to be verified in the field:
Inspector
Notes:
Date:
lJVll All LV �.Vaaa avw ww av+av ��++•
Violations:
(j/N
If so, List: t n
Proffers:
®/N
If so, List: 2
Variance:
Y/I ,
If so, List:
SP's:
JY) /N
so, List;
-57
Clearances:
SDP's
Revised 7/1/2011 Page 3 of