HomeMy WebLinkAboutCLE201600125 Application 2016-05-24Application for Zo.
CLE # Q61 k" I
PLEASE REVIEW ALL 3 SHEETS
PARCEL INFORMATION
Tax Map and Parcel: (Id _--�-
Pared
Clearance
OFFICE USE ONLY
Check # J Date:
Receipt # I Stan;
Fashto
Parcel Address: 1 b O O C. W O R Oa c) City
(include suite or fluor)
— Existing Zoning
uare ma II
Chzrl o tt esu l 1 kate
V2.
%p CI01
PRIMARY CONTACT
Who should we call/write concerning the; project? �T�� _S-e �Ai t-[[)t�
Address %06 City C L11GState
- — Zip 2u1 a
Office Phone: f yell ��� ti3sl ^Cell # - l@�-1x # E-mail SmaQztlNgpwaA :C,
APPLICANT,' INFORMATION
Check anythat apply: Change of ownership Change of use Change of name New business
Business Namerfype: 114Q-G V ►� t�acV'Ri N1 �[7_�i
Previous Business an this site
Describe the proposed business including use, number of employees, number of shuts, available parking spaces, number of
vehicles, and any additional information that you an provide; 2 .' ri
�.
�C Ox Q
"This Clearance will only be valid on the parcel for which it is approved. If you change, intensify or move the list to a new location, a new Zonin
Clearance will be required.
I hereby certify that I own or have the owners permission to use the spare indicated on this application. I also certify that the information provided
is true and accurate to the of my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by fiv,= G r
Signature « Printcd _ �(yIJYYUI.@... i�U -+ C/Z-�.�
APPROVkLINFORMATION
[ ] Approved as proposed I ] Approved with conditions
[ ]Denied
[ ] Backttow prevention device and/or current test data needed for this site. Contact ACSA, 977-4511, xl 17,
[ ] 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 cornplies with the site plan as ofthis date.
Notes -
Building Official
Zoning Official
Other Official
Date
1
Date
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 2%-M32 Fax.: (434) 972-4126
PQ/064.1(3 4"u-I' W� V i-�-b f� Revised 1I/1/ZO1SPage 2of3
g'%81 , Oita..
Intake to complete the following:
YlN
Is use in LI, M 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 from Health
Dept. FAX DATE _
Circle the one that applies
Is parcel on private well or public water?
If private well, provide Health Department form,
Zoning review care not begin until we receive approval from Health
Dept, FAX DATE
Circle the one that applies
Is parcel on septic or public sewer?
YIN
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y l Willl ere be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zonine to complete the followine:
Reviewer to complete the following:
Square footage of Use:
Permiittted as: _Vmp sa uz wl-
Under Section:
Supplementary regulations section:
Parking formula:
Required spaces:
Y/N
Items to be verified in the field:
Via s:
Yf�•
If so
Proa Mrs,
Yl N
If st:
Vari e:
Y!
If sv, Est:
SP's:
YIN
If so, List:-
Clearances-
SDP's
Revised 1 I 2015 Page 3 of 3