HomeMy WebLinkAboutCLE201600095 Application 2016-04-26Application for Zo ing Clearance' hf
CLE It
FR
FFICE 17 E NLY
PLEASE REVIEW ALL 3 SHEETS heck # Date:
eceipt # Staff:
PARCEL INFORM
Tax Map and Parcel: Existing Zoning
1 y
Parcel Owner-
Y � L
Parcel Address: -City State Zip
L
(include suite or oor)
PRIMARY CONTACT
Who should we call/write concerning this project?�
Address • J2f s_ � C cc �.Q_ �YQ � City � f�L State \1[ 4 Zip .. ZZ- f
Office Phone: Z 3 - b Cell # L,7 06cF Fax # 2-?3-9-t 1- f E-mail u_#ev4C! C�-
C'a L X..
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name/Type: y ! ei
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 1 Printed Lc/ A, -He r?�
APPROVAL INFORMATION
Approved as proposed [ ] Approved with conditions [ ] Denied
[ ] Backflow prevention device and/or current test data needed for this site. Contact ACSA, 977-45I 1, xl 17.
[ ] No physical site inspection$as 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 ofthis date,
Notes:
Building Official Date t
Zoning Official Date L
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 I I/1/2015 Page 2 of 3
Intake to complete the following:
Reviewer to complete the following:
�'IN Square footage of Use:
s use m LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet. 0/ N
ermitted as:
YIN
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
Circle the one that applies
Is parcel on PPMa ell or public water?
If private we ide 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 septic or public sewer?
Y / Qj
Will you be putting up a new sign of any kind?
Sign permit.
Permit #
If so, obtain proper f
Yl
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the following:
Parking formula:
Required spaces:
Y/N
Items to be verified in the field:
Inspector • Date:
Notes:
Violations:
Y/6+
If so, List:
Proffers:
Y/
If so, ist:
Varia ce:
Y/(
If so, st:
P's:
�IN
If so, List:
Clearances:
SDP's
Revised 11/112015 Page 3 of 3