HomeMy WebLinkAboutCLE201600194 Application 2016-09-28Application for Zonine Clearance
CLE # %i 0 j j , �t
OFFICE �I,Y
PLEASE REVIEW ALL 3 SHEETS Check # `�
Receipt # Staff•
PARCEL INFORMATION
Tax Map and Parcel: -- — 0 4a 11 q Existing Zonin e'l e ':$`
Parcel Owner: e
Parcel Address: „2 $11_U Sfe City ��a.� co'-fle State V4 Zip ZZ�//
(include suite or floor)
PRIMARY CONTACT r
Who should we call/write concerning this project? Ct V 1l' a b4+s
Address : 3 0L H r cVr1a 17 Rd S+e Zi? 2 City U W 1 SL.0 1 e State V4 Zip Z 2-9/1
Office Phone: Cell # 43\ �,' yl�t{f Fax # E-mail rtya �7c� r
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
r
Business Nameflrype: Pc Jc-r c &c (o r cj C S eig4 c 14 0 7, ,a
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:
a
fI AT
*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 Iown or have the owner's ermission to use the space indicated on this application. I also certify that the information provided
is true and accurate o the be ` of my kno edge. v e conditions of approval, and I understand them, and that I will abide by them.
Signature Printed & dui &Y14 CPS OY-�p
APtR6VAL INFORMATION
[ Approved as proposed [ ] Approved with conditions [ ] Denied
[ ] Backflow prevention device and/or current test data needed for this site. Contact ACSA, 977-4511, x117.
] No physical site inspection has been done for this clearance. Therefore, it is not a determination of compliance with the existing
site plan.
f ] This site complies with the site plan as of this date.
Notes:
Building Official Date
Zoning Official Date
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 11/1/2015 Page 2 of
Intake to complete the following:
Y/N
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y l
Will ere 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 Iic water?
If private well, provide Heal ent form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applies
Is parcel on septic o A- lic sewer?
Y l�N
Will u be putting up a new sign of any [rind? If so, obtain proper
Sign permit.
Permit #
Y nN
Wi ere be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
ZOnmlr to COMDlete the
violns:
Y/set:
If so,
Va e:
Yl/If so, ist: ,
Clearances:
Reviewer to complete the following:
Square footage of Use:
N
rmitted as:
Under Section: _ 9154
Supplementary regulations section:
Parking formula:
Required spaces:
YIN
Items to be verified in the field:
Inspector
Notes:
Pro
YI
If so'Mist:
WE
If so
If so is
SDP's
Date
Revised 11/1/2015 Page 3 of 3
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