HomeMy WebLinkAboutCLE201600224 Application 2016-10-07.,
Application for Zoning Clearance
CLE # 22} -/994
OFFICE U E ONLY '
PLEASE REVIEW ALL 3 SHEETS Check # D Date: 2
Receipt # !�Staff;
PARCEL INFORMATION
Tax Map and Parcel: Existing Zonin
lZ
Parcel Owner: r,,
Parcel Address: a 03 5 60�_'p 5�- City A trs�li , State vl t11 zip 14'
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project?
Address : city Lr e_1) jl Sti2 !YI Iate !zip4g�
Office Phone: �I i - ell p
APPLICANT INFORMATION
Check any that apply: Cbange of
Fax # E-mail
of use Change of name New business
Business Name/Type: [A /U C�
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: 1 e+e'C j Y
S n�
*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 own or have the owner's permissto use the space indicated on this application. I also certify that the information provided
is true and accurate to the best of my knowledge. I ve ad the conditions of approval, and I understand them, and that I will abide by them.
Signature iJ Printed 6 b7,0-8E+M 6 Ly/vA/
APPROVAL INFORMATION
Approved as proposed [ ] Approved with conditions [ ] Denied
[ ] Backflow prevention device and/or current test data needed for this site. Contact ACSA, 977-45I 1, 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
Zoning Official
Other Official
Date
Date
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: ' Reviewer to complete the following:
�' / Square footage of Use:
Is us- LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet. l) / N
Permitted as: f`
Y /
Will ere be food preparation? Under Section: �- e. -� e. 0.
If so, give applicant a Health Department form.
Zoning review can not begin until we receive approval from Health Supplementary regulations section:
Dept. FAX DATE
Circle the one that appli�Car�jtphl��1,2a:ent
Is parcel on private weer?
If private well, provide form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applies
Is parcel on septic or ublic sewerPI
.
YIN
Will you be putting up a new sign of any kind?
Sign permit.
Permit #
Parking formula:
Required spaces:
Y/N
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 #
Zoning to complete the following:
Viola ,ons:
Proffers:
Y /�
If so, ist:
f so, List:
o,
,
n1 2�1 7
Varia
SP's:
Y/
Y/N
If so, st:
If so, List:
Clearances.
SDP's
al —
Revised 11/1/2015 Page 3 of