HomeMy WebLinkAboutCLE201600175 Application 2016-08-08Appf.cadon fo
Zo i g Clearance
CLE #
i
0WICI Y
PLEASE REVIEW ALL 3 SHEETS
Check Date; W
Receipt # Staff:
PARCEL INFORMATION
Tax Map and Parcel: O LA (aZ'A -00.06 • oo i4 o Existing Zoning
Parcel Owner: S p /� emr
L:
Parcel Address: l U_�)AAN Po_�
-
City C 1+= L411b_State J Zip t
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project? -
Address; t-4 6k uJ.7kir- pfx kk
city Oy t i _:c State JA— ZIP Opp 14l
Office Phone: (,ig •03z%) Coll # o 6-+1 S nX # &6Xt3 E-mail i iN� . ckn� +mac A. Ci
APPLICANT INFORMATION
Check any that a ; Change ormmership
Change of use Change of name Now business
0
Aaeiness NameArype: ems. ti
Previous Business on this site
Ilwrlhe the Proposed business including use, number of
vehielIs, and ,any addll"al iafc fmatlon Rmt you can pre,
of
*This Clearance will only be valid on the parcel fur which it is approved. If you chango, intensity or tnove the use to a new location, a new Zoning
Ciearance will be required,
I hereby certify that I own or have the
is true and aaonllate to �gm t
Signature _
APPROVAL IN,FORAIATIOP+N
Permission m use the space indicated an this application, I also oertity that the information provided
le. I have read the conditions ofspprovA and I undendand them, and Ow I will libido by them.
Printed i f�1L t � LAkx \
[ ] Approved as proposed [ ] Approved with conditions [ I Denied
f ] Backilow prevention device and/or current test data needed fords site. Contact ACSA, 977-451 I, xl l7.
[ I No physical site inspection has been done for this clearance. Thorofare, it is not a derorrnftW1on of compliance with the existing
site plan.
[ I This site complies with the site plan as ofthis date.
Building Official
Zoning Official
Other Offiefal
Date zd
ff t (a
Date
Date
County of Albemarle Department of Community Development
dill McIntire Road Charlottesville, VA 22902 Voice; (434) 296-5932 Fax: (434) 972-4126
Revised 11/1/2015 Page 2 of 3
N_
to complete the following:
Y
Is use in Ll, HI or PDIP mnieg5? If so, give applicant a Certified
Engineer's Report (CER) paclret.
Y 1�b
Will there be food preparation?
If so, give applicant a Heald: 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 weal or p!t� �Jkt.tIf private well, provide Health form.
Zoning review can not begin until we receive approval from Health
Dept, FAX DATE
Circle the one that ap '
Is parcel on septic ubiic sewer?
YIN
Will you be putting tip a new sign of any kind? If so, obtain proper
Sign permit.
Permit o
YIN
Will there be any new construction or renovations?
Ifso, obtain the proper Permit.
Perimlt #_
Zoning to complete the following:
Reviewer to complete the following:
Square footage of Use: 3 r-5 7
60/N ,
Permitted as: 0
Under Scotian:. G �Z•_ Z. 1
Supplementary regulations section:
Parking :formula:
Required spaces: 1-5
YI
Items to be vetifled in the field:
Impactor; Date:
Notes:
Vlanatlena:
YIN
If so, List:
Preti
/OV
lfso;Lbt
Vari We:
Y I(N
if sa, ist:
SP's•
Y 1vI
If so, psi;
Clearances:
SDP's
Revised 1111/2015 Page 3 bf 3