HomeMy WebLinkAboutCLE201600148 Application 2016-07-28Application for Zoning Clearance
lI :
CLE #fit ..11-4'g
..fFi'lll
r
,..
1 fIR-,4��a
PLEASE REVIEW ALL 3 SHEETS
OFFICE USE ONLY
Check # (dip CM I' Date: (o --0
Receipt # � 'i Staff:
PARCEL INFORMATION --
Tax Map and Parcel: 011b U- O k- 00 - ta500 Existing Zoning
Parcel Owner:— �koe-17,6 gow-, T i_-0-
Parcel Address: N2O IJJuAmt.(,n ROM U4 0103 City Ur: g Lo-M6,I111 tate \JA Lip aacll,j '
(include suite or floor)
PRIMARY CONTACT AiA
Who should WA-1?Se2)
we call/write concerning this project?
� n r
Address : 02/Nl�l ! L �t Ci ii� a,:! State Zip "o
Office Phone: ( Cell #5X6--?D5- � # E-mail
APPLICANT INFORMATION
Check any that apply: Change of
Business Name/Type:
Previous Business on this site
Describe the proposed business including use, number of empl
vehicles, and any additional information that you can nrovide:
of use Change of name New business
*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 have the owner's permission to use the space indicated on this application. I also certify that the information provided
is true and accurat st of my knowledge. I have read the conditions of approval,
and I understand them, and that I will abide by them.
Signature Printed N"sr0 6&'5��
APPROVAL INFORMATION
[ Approved as proposed [ ] Approved with conditions [ ] Denied
[ ] Backflow prevention device and/or current test data needed for this site. Contact ACSA, 977-451 1, 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-511 -S
Zoning Official Date hu
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 11/02/2015 Page 2 of 3
Intake to complete the following:
Y %O
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
YIN
Will t zerc 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 pc er?
If private well, provide Heal partment 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 pa c se r?
L�
YIN
Wi be putting up anew sign of any kind? If so, obtain proper
Sign permit.
Permit #
YIN
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit # BAD %5 c)(3sri3
)ninLy to complete the
Var' e:
YiN
If ist:
Clearances:
Reviewer to complete the following:
Square
ol
Square footage of Use: p lr�
/ it
ermitted as:
)M� � N,
Under Section: `h,(c
Supplementary regulations section:
Parking formula: i
Required spaces:
YI 14)
Items to be verified in the field:
Inspector : ZDate:
Notes:
I
Pr
Ysvi
If :
's:
YIN
f so, List:
SDP's
Revised 11/1/2015 Page 3 of3