HomeMy WebLinkAboutCLE201600094 Application 2016-08-08Application f r o ing (Clearance `
CLE # �• : t4-
OFFICE
PLEASE REVIEW ALL 3 SHEETS Check # Date: `
Receipt # Staff:
PARCEL INFORMATION
Tax Map and Parcel: Existing Zoning /an-wc'
Parcel Owner: $T�T%fTt7�t1 ✓FaJ'T(� / ZLG
Parcel Address:_ 22� ALHA677-WWA V. CityState VA Zip pow
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project? DAB �tk�
Address : ,sin/ &WA0 City & State 6A Zip 301/3%
Office Phone: (79o)6" —fs3oo Cell # *41 .'iV #%?Fax # 7;b-L9ZE-mail Phq&57lAG«NS�
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name -X_ Neiv business
Business Name/Type: ��®N000�� /�pG�!/1%(s ZQQ
Previous Business on this site �o-W' r ��(�C_t/,t/D%� sei�
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: r %
*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 ne%v Zoning
Clearance will be required.
I hereby certify that I own or have the owner's permission to use toe space indicated on this application. I also certify that the information provided
is true and accurate to est of my knowledge. I have read die conditions of approval,, and Iunderstand them, and that I will abide by them.
Signature Printed f 1MOTH`{ C. Wsu iAr a --
.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 I, x117.
[ ] No physical site inspection has been done for this clearance. Therefore, it is not a deterEnination of compliance with the existing
site
[ plan-
] This site complies with the site plan as of this date.
Notes-
Building Official Date
Zoning Official Date Z-ZJ
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 7/1/2011 Page 2 of 3
L
Intake to complete the following:
Y/I
Is use in LI, HI or PDIP zoning?
Engineer's Report (CER) packet.
If so, give applicant a Certified
Y / pQ)
Will }ire 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 Parking formula: I
Is parcel on private well or blic wa r? ` "0
If private well, provide Heal ment form.
Zoning review can not begin until we receive approval from Health Required spaces:
Dept. FAX DATE 22
Reviewer to complete the following:
Square footage of Use: _. 19 737
(3 / N ]
Permitted as:
Circle the one that applies
Is parcel on septic or. public sewe .
YIN
Will you be putting up anew sign of any kind?
Sign permit.
Permit #
Under Section: 2-5 A . 2 .
Supplementary regulations section:
YI
Items to be verified in the field:
If so, obtain proper
Inspector : Date:
Y / N Notes:
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit # 246 — <07 6(::/
7�oning to complete the followinLY:
Violations:
Y/�
If so, —List:
roffers:
WY/N
If so, List:
Variance:
YlP)
If so, ist:
SP's:
YI
If so, ist:
Clearances:
SDP's
Revised I l/l/2015 Page 3 bf 3