HomeMy WebLinkAboutCLE201600021 Application 2016-02-09CLE # w
OFFICT
PLEASE REVIEW ALL 3 SHEETS Check #
Date-
stgff-
PARCEL
INFORMATION
Tax Map and Parcel• _ _ / Exhfing zoning—C — Comm t'ri-c 110 (►
Parcel Owner: *04 LTY "71% L L f.
Pairceel Address:_ y1Z�7+'l til CI12eC SK 200 city _C'A jtL4fT�Ygb`state _ I�JQ -- - zip�2 �j
......... ......
(include suite or floor)
PRIM ARY CONTACT
Who should we call/write concerning this project? �i�Z oT/ PGAI+�NINL G�6up LtG �dTiN,, %/!�f MJLL 6)%,
Address: MAW"W L OCCO, ST -a o _ C4QMAt.0TT610LAt State
Ofilte Phone: 912- Ceti # F.ax W._ 1 mai! 1MIkILQIr eX f1711O1 CO
UeUoil-UTAI
Check Any that apply-, Change of ownership Chan a o4useChaagc of panne Now business
Business Nawarrype: 1 1 A1VNJAf6- Cr goul LL. G PIlBfFt7► L t'�/G//1/ ir%S
Previous Business on this site UNk a W
Describe the proposed business including use, number of employees, number of shifts, available parking spaces, number of
vehicles, and any ditio information that you can provide; eXC =M/&"L 42L&JIv2�7t/NG� s �°7V1i�L4
"Thus Clearaaca Y411 only be valid on the parte? fox which it is approved. If you change, lutmsify or move th:; use:-) a nein Ie -n -mon, a of Zonine
Clearance will be required.
I hereby certify that I own or have the ownee's perrxrission 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 abids by them.
Printed- __-*"0'ffyec�/%_�G G 0"._
APPROVAL INFORMATION
Approved as proposed [ ] Approved with conditions [ ] Denied
] Backflow prevention device and/or current test data needed for tills site. Contact ACSA, 977-4511, x] 17.
[ ] No physical site inspection has been done for this clearance. Therefore, it is not a detamination of compliance with the existing
site plan,
[ ] This site complies with the site plan as of this date.
Notes:
Building Official T~ Date r�
Losing Official Date�`�C G�
Dther Official Dat,ie
County of Alba marle Departesient of Community D,-vt'lopm%.Anf
441 McIntire Road Charl6ttesviiie, VA 22902 Voice: (4Z.t) 2%,15332 P'= (434) 972-4126
Revised 1 ] 11/2415 Page 2 of 3
Intake to complete the following:
y
Is use in Ll, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CBR) packet.
Y /Gi
Will these 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 or pulie WA
If private well, provide He4th Ont form.
Zoning review can not begin until we receive approval from Health
Dept, FAX DATE
Circle the one that applies �;ewo-
Y
Is parcel on septic of pF
/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
YIN
Will there be any now construction or renovations?
If so, obtain the proper Permit.
Permit #
7nniwn fn nmmimla+a the fn] lnsumKF-
Reviewer to complete the following -
Sq Uarr
ollowing:Square footage of Use, �� J
y1N
Permitted as:
Under Section: ';L:'2 •2 - ]
Supplementary regulations section:
Parking formula:
Required spaces:
• a /�i
Items to be verified in the field:
Inspector•
Notes:
hate:
Violas ons:
Y
If so, List:
Proffers:
Y/O
if so, List:
Variance,
tyN
If so, List:
SP's:
YIN
If so, List:
Clearances:
SDP'o
Revised 11/1/2015 Page 3 bf 3