HomeMy WebLinkAboutCLE201600203 Application 2016-09-30Application for Zoning Clearance
CLE # MA
OFFICE U NLY _
PLEASE REVIEW ALL 3 SHEETS Check # Date:
Receipt # Staff,
PARCEL INFORMATION �G,b
Tax Map and Parcel: — Ot 70 Existing Zoning _
Parcel Owner: ?' s !rl
Parcel Address:4.14y- r I City State Zip
(include suite or fla r) vok,
PRIMARY CONTACT I
Who should_we77c��all/write concerning this project. Al
��Q.LI� p
Address: US.'3 0 urge, � j.�.� City M ,-T State Zip
Office Phone: r `i'"TS Cell # O44 Fax # E-mail t�lArT
r
. Ca vv1
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name/Type: Alt 0
Previous Business on this site
Describe the proposed business including use, number of employees yumber of shifts, available pa ki' g spaces, number of
vehicl and any additional information that you can provide: "-5Ip tj tO Z'
AW
*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 r have the owner's permission to use the space indicated on this application. I also certify that the information provided
is true and accurate the est of ]mowled e. 1 have read the conditions of approval, agdLunderstan them, and that I will abide by them.
Signature Printe O
APP VAL INFORMATION
[ Approved as proposed [ ] Approved with conditions [ ] Denied
[ ] Backflow prevention device and/or current test data needed for this site. Contact ACSA, 9774511, xI 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 PAJ Date is
Other Official Date
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (434) 972-4126
A13
Revised 11/1/2015 Page 2 of 3
Intake to complete the following:
Y N
Is u LL HI or PDIP zoning? If so, give applicant a Certified
En gi er's Report (CER) packet.
Y
Wi 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(unfil�we
liwate .
If private well, provide Hea ent form.
Zoning review can not begi receive approval from Health
Dept. FAX DATE
Circle the one that appl'
Is parcel on septic or ublic sewer
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y/N
Will there be any new construction or renovations?
If so, ob er
Per; #
Zoning to complete the followin
Reviewer to complete the following:
Square footage of Use: 1113
Permitted as: W&K
Under Section: } A� _
Supplementary regulations section:
Parking formula:
Required spaces:
Y N
Ite be verified in the field:
Inspector : Date-
Notes:
Viol s:
Y/
Ifs
p e
if
if Su4st.
Va ' nc :
Y
s ,
Y
If s ot:
Clearances:
SDP's
Revised 11/1/2015 Page 3 bf 3