HomeMy WebLinkAboutCLE201500169 Application 2015-08-31py :� L/A,
Application for Zonin Clearance
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CLE# aaiS-- 11 J
OFFIC)✓ USE ONI us
PLt ASE REVIEW ALL 3 SHEETS Check# 1 Date: $
Receipt # 1 D O� L*t3 Staff':
452�—
PARCEL INFORMATION_] � % �j 7� �1 Deye, oc�yyrQvti
Tax Map and Parcel: / L 1 / �! 1 Existing Zoning
Parcel Owner:Vk
Parcel Address: -/4, ��� t` G(2e1�-b/r ity ^�'`� S��c'State Zips Q
(include suite or floor)
PRIMARY CONTACT a
V1'hlo should we call/write concerning this project? `o n r
Address : (�� V ( City l a%/A`State Zip
43+ ` `
Office Phone: (_) Cell # �l 5o94= Fax # E-mail i7ok� � E:4�'1 LkZL--\
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 cerIthator h vqeow, er's permission to use the space indicated on this application. I also certify that the information provided
is true and aofledge. Ihave read the conditions of approval, and I understand them, and that I will abide by them.
Signature Printed
-
APPROVAL INFORMATION Denied
j Approved as proposed [ ] Approved with conditions [ ]
[ ] 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 compl ies with the site plan as of this date.
Notes:
`�— Date�lr(�
Building Official 1
Zoning Official v Date/ Z ci /-�'`C
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
Q
Intake to complete the following:
Y/N
Is use in LI, 1-I1 or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y /N�
Will there be food preparation?
If so, give applicant a Health Department form.
Zoning review can not begin until we receive approval rrom Health
Dept. FAX DATE
Circle the one that applies
Is parcel on private well o public 9`
If private well, provide Healt apartment form.
Zoning review can not begin until we receive approval from Health
Dept, FAX DATE
Circle the one that applie
Is parcel 'on septic o. public sewer?
� / N
Will you be putting up anew spgn of any kind? If so, obtain proper
Sign permit. �� lzi)
Permit #
VVN
there be any new construction or renovations?
If so, obtain the proper Permit.
Permit t#
Reviewer to complete the following:
Square footage of Use:
�lN f
Permitted as:
Under Section: Z�� 2 • l
Supplementary regulations section:
Parking formula:
0
Required spaces: ,)
Y/N
Items to be verified in the field:
Inspector:
Notes:
Date:
zoning to complete the following:
Viola ons:
Y/V
If so, List:
Prof V.
Y/
If so, List:
ariancc:
/N
If so, List: q
SP'
1'
Ifso, ist:
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3