HomeMy WebLinkAboutCLE201500200 Application 2015-10-12Application for Zoning Clearance
CLE # J106- ftW
OFFICE'LY
PLEASE REVIEW ALL 3 SHEETS Check # Date:
Receipt # Staff:
PARCEL INFORMATION
Tax Map and Parcel: IN)xisting Zonin
Parcel Owner:
Parcel Address:_ op E Citycharl tate Zip
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project? 01-kfXr1J1U
Address: Co C w- ��) i City 646
. to State Zip
Office Phone: Q� 3D �3, C&P \ii Cell # Fax # E-mail >vT;@ r. & . (w,
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name/Type: _ r*
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 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 best of my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature Printed
APPROVAL INFORMATION
Approved as proposed [ ] Approved with conditions [ ] Denied
[ ] Backflow 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 site complies with the site plan as of this date.
Notes
Building Official Date
Zoning Official r. Date U >5
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/l/20I I Page 2 of 3
Intake to complete the following:
y/(
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
MM
Will 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
Is parcel on private well r pub ' ater?
If private well, provide Heat Department form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that api��p
Is parcel on septic or
YIN
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y/N
Will there 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: /1 0,)o
0/N
Permitted as: 5- AY Te�n,p V,
Under Section: 'LP,
Supplementary regulations section:
Parking formula:
Required spaces:
YI
Items to be verified in the field:
Inspector : Date:
Notes:
Violations:
(
If so -,-List:
Pro s:
If so st:
Variance:
6/N
If so, List:
SP'ss:�
Y/3
If so, ist:
Clearances:
SDP's
�S�Jd7i
Revised 7/1/2411 Page 3 of 3