HomeMy WebLinkAboutCLE201500198 Application 2015-09-29qY' Ai.
Application for ZonlnLy Clearance_
CLE #�
OFFICE USE ONY
PLEASE REVIEW ALL 3 SHEETS Check # Date:
Receipt # 101 T9 Lf Staff: f� �
PARCEL INFORMATION
Tax Map and Parcel: Existing Zoning e r C61M
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Parcel Owner: i� 1,�, [Q Law° `�p_ a
Parcel Addres �V City _ State v "[ Z;;9 ` I
(include suite or floor)
PRIMARY CONTACT - n
Who should
we call/write concerning this project? n � �� /
Address : �� iJ �J �f� � o6y d G�tate V Zip -
Office Phone: 5 `IVell # 40 ` `SU Oi l� 3 E-mail L t39 �1 l�lL iy I'v �y
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
BusinessName/Type-, U���
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 certi that I own or have the owner's ermission to use t pace indicated on this application. I also certify that the information provided
is true and ac to best o y knowledge. a conditions of approval, and I understand them, and that I will abide by them.
Signal urd Printed ��LAA&Mvttuz�
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APPROVAL INFORM9TION
J 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 complies with the site plan as of this date.
Notes:
Building Official Date - C?(-z�[ c
Zoning Official Date )
Other Official Date
County of Albemarle Department of Community Development
40I McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (434) 972-4126
Revised 7/1 Ml I Page 2 of 3
Intake to complete the following: Reviewer to complete the following;
Y 16) Square footage of Use:
Is use in L1, H1 or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet. 6 1 N
Permitted as:
Y 1
Will e be food preparation? Under Section:
ther
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 /
Parkin formula: y
Circle the one that a lies gGIY�r[�''e'�
is parcel on 11 or public water?
—
If private we , ade Health Department form.
Zoning review can not begin until we receive approval from Health Required spaces: 4
Dept, FAX DATE Y /
Circle the one that applies Items to be verified in the field:
Is parcel on ptce public sewer?
Y 1(9
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit. Inspector : Date:
Permit #
Y 16)
Dotes:
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #I
Zoiling to complete the following:
Viola ons:
Y 1
Pro s:
Y N
If so, List:
If so, List:
Vari ce:
,q
SP's-
Y 1
Yn; List:
If so, ist:
Clearances:
SDP's
Revised 7/1/2411 Page 3 of 3