HomeMy WebLinkAboutCLE201400232 Application 2015-07-27Applicati®n f®r Zoning Clearance
CLE # 7 b I y - Z3 Z
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OFFICE USE ONLY
PLEASE REVIEW ALL 3 SHEETS
Check # 1 11 C1 / Date: I rL It/
Receipt # q$02-& Staff:
PARCEL INFORMATION
Tax Map and Parcel: 06-10o -OU •Ub -0 4 C46c) Existing Zoning
Parcel Owner: - tell ung
s,
ZS '3 State Zip
Parcel Address: 14wg ` A.,- City i 4
(include suite orfloor)
PRIMARY CONTACT
Who should we call/write concerning this project?.�� �l t
Address l-� O.41 � �%/ �/ City State G zip ZLSd t
Office Phone: 4ib `3ynst,94. Cell # gS3-5!2-Y Fax # Z1t 3-dGrt3 E-mail & J/3Ja- e die" -oma:
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name z. -New business
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Business Name/Type: I-� t (- MG,d (_ s �a� 1�:.►�
/mon
Previous Business on this site � p /?om 2
Describe the proposed business including use, number of employees, number of shi s, available parking s aces, number of
of
vehicle and any add' 'onal information that you can provide: otljut � _ 1 ,KR10!eeC-
- �rlilWe"- 3�il(.C,
*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 w or ha the owner's permission to use the space indicated on this application. I also certify that the information provided
is true and accura t e best of iy knowledge. I have read the conditions of approval, an I understand them, and that I will abide by them.
Signature Printed 'tt
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 com lies with the site plan as of tl is date.
Notes: C. , f) 10()- nerm 1, f 1:2A l "�" l kv' D. g
Building Official `' Date l�
Zoning Official 4Date
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:
Reviewer to complete the following:
Y / N
Square footage of Use:
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y / N
Permitted as:
Y/N
SP's:
Y/N
If so, List:
Will there be food preparation?
Under Section:
If so, give applicant a Health Department form.
Zoning review can not begin until we receive approval from Health
Supplementary regulations section:
Dept. FAX DATE
Clearances:
Circle the one that applies
Parking formula:
Is parcel on private well or public water?
If private well, provide Health Department form.
Zoning review can not begin until we receive approval from Health
Required spaces:
Dept. FAX DATE
Y
Circle the one that applies
Items to be verified in the field:
Is parcel OscgaDor public sewer?
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit # Inspector : Date:
Y�� Notes:
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the following:
Violations:
Y/N
If so, List:
Proffers:
Y/N
If so, List:
Variance:
Y/N
If so, List:
SP's:
Y/N
If so, List:
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3
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