HomeMy WebLinkAboutCLE201600201 Application 2016-09-30Application for Zo ' g Clearance
CLE # -
OFFICE i1 NLY
PLEASE REVIEW ALL 3 SHEETS Check # Date:
Receipt # Staff:
PARCEL INFORMATION G�
Tax Map and Parcel: — t0 — o7000 Existing Zonin
iz
Parcel Owner: �>1 Q 41111
Parcel Address: Y /'TV' City 0 -� StateVZip
(include suitefor floor)
PRIMARY CONTACT
Who should we call/write concerning this project?�t- O LI
Address: CA539r l�D6tI 0LW-a-e, k}QL CityCr 0 AA- State Q . Zip Q3
Office Phone: — Cell # Fax # E-mail
APPLICANT INFORMATION
Check any that apply: Chan Le of ownership Change of use Change of name New business
Business Nameffype: U%J
Previous Business on this site N O lJ p
Describe the proposed business including use, number of employees nujfiber of shifts, ailable parking;�aces, n tuber of
v id , and any additional information that you can provide: j Ty ,Z ,t,y,�i9 &�Id�D�
*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 ljdAor have the owner's permission to use the space indicated on this ap lication. I also certify that the information provided
is true and accurate the est of¢iy knowledge. I have read the conditions of approval, an K)inderstandXem, and that I will abide by them.
f
APP MVAL INFORMATION
[04pproved as proposed [ ] Approved with conditions [ ] Denied
[ ] Backflow 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 complies with the site plan as of this date.
Notes:
Building Official Date �� - (�
Zoning Official Date __ q' raj
Other Official Date t�`�
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 3
In C
to complete the following:
YIs LI, HI or PDIP zoning? If so, give applicant a Certified
EngigQerts Report (CER) packet.
Y N
W' 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 p blic wa ?
If private well, provide Healtha artment form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE _
Circle the one that appl'
Is parcel on septic or ublic sewer?
YIN
Will you be putting up a new sign of any kind?
Sign permit.
Permit #
If so, obtain proper
YIN
Will there be any new construction or renovations?
If so, obt er
Permit #
Gonme to complete the followine:
Vie s:
Y
If s lst:
Vari e:
Ifl
If so, st:
Clearances:
Reviewer to complete the following:
Square footage of Use: 0 �`f1
ZWm tted as: 1
Under Section:
Supplementary regulations section:
Parking formula:
Required spaces: V l
Y f N) I—
Ite be verified in the field:
Inspector : Date:
Notes:
Revised 11/1/2015 Page 3 of 3