HomeMy WebLinkAboutCLE201500056 Application 2015-06-11Application for Zoning Clearance
0
PLEASE REVIEW ALL 3 SHEETS
OFFICE USE O Y
Check# O Date:
Receipt # �e'' , Staff:
PARCEL INFORMATION (�
Tax Map and Parcel:b D i 7 Existing Zoning
Parcel Owner: ' o Oc. o a /iSJ C1Lt J)-iM
Parcel Address: C2t 5 t "X� Q,Qf� (yam. (City a1(?1}' State Vt Zip
(include suite or floor)
PRIMARY CONTACT �
A�.%c.� LO
Who should we call/write concerning this project? f, 'Uf (� (
Address: 1,1 11 e&)od Am. City (L State Zil�_-
Office Phone: Cj�'4) -t� �- z 1 Cell # t� ��{ %,(,2 y�V Fax # t(- PJJ 013 -6(!5E -mail UH v`Q , -a ' odmo✓b1� jM
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use New business
Business Name/Type: o, � ` F1mi1(z13 1 ) 1
�rA.S� � �' Y 5
Previous Business on this site l y ( a ? , �` �� 6, -1 �1 d ' tAY -t 't a "M
Describe the proposed business, including use, number of employees, number of shifts,, available park'1 spais, number of
vehicles,And any, additional infrmation hat you can provi e: GPS U' U '�
�
�
Cca.�., c /"�:r'll .• JC-L� �It�V>'1�QYS
*This Clearan sr771 only be valid on thb parcel for which itis approved. If you 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 inf'onnation.provided
is true and accurate ` the est o£ my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
1
Signature Printed yw i,1
AP OVAL INFORMATION
[ Approved as proposed [ ] Approved with conditions [ ] Denied
[ ] Badk- low prevention device and/or current test data needed for this site. Contact ACSA, 9774511, 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 s'te complies withlie site planas of this -date.
Notes 6
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:
Is u�� LI, HI or PD1P zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y N
ill 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 Jtl'1( U�re- 10 Yl, t Y` CLA UQN4-01�
Is parcel on private well or public water? Y
If private well, provide Health Department form. hp,n
Zoning review can not begin until we receive approval from east
Dept. FAX DATE I - t
Circle the one that applies ��-0 (�"'1 �' J()Vi� S
Is parcel on septic or public sewer? bAa+—et,; PYA
Y/N APT
Wil. be putting up a new sign of any kind? If so, obtain proper
Sign permit,
Permit #
Y /(Wii re be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the following:
Reviewer to complete the following:
Square footage of Use:
ITermitted as: _-kil10
Under Section: Am
Supplementary regulations section:
Parking formula:
Required spaces:
d
Y/
Ite o be verified in the field:
Inspector•
Notes:
Viol i s:
YIN
Ifs ist:
Pro s:
Y N
Ifs , ist:
ar' ce:
/
s Z
SP's:
Y/N
,List:
IN
v
Clearances: , � �
v l ' 10eW
SDP's
FMWA 'V 4
Revised 7/1/20011 Page 3 of 3