HomeMy WebLinkAboutCLE201600240 Application 2016-10-21Application for Zon''iIn^g Clearance
OFFICE [/i��E, ONLY
PLEASE REVIEW ALL 3 SHEETS Check # &,, Date: 20
Receipt # . I t) p `] -7 Staff:
PARCEL INFORMA
Tax Map and Parcel:
Parcel Owner:
Existing Zonime a I eammcycij
Parcel Address: ? Av-) k- a�-8 Cityn(�`(� (TCiC&IJ State \FA Zip "G
(include suite or floor)
PRIMARY CONTACT 1�
Who should we call/write concerning this project?
Address; 3�� 6`��- City=s1��5+� `1�Q -- State Zip
Office Phone: {�� Cel'9 Ackaz # E-mail,5cNeo--� i (C-b MN,
APPLICANT INFORMAATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name/Type: C1^oSs d-15 Cf�yl`1� 1 hc�
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:
*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 hav er's permission to use the space indicated on this application. I also certify that the information provided
is true and ac 'the b o kn wledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature \_� Printed � V e— C�'�'} h�
APPROVAL INFORMATION
J 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.
[ ] This site complies with the site plan as of this date.
Building Official
Zoning Official/
Other Official
Date IQ i�,
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 3
Intake to complete the following:
Y / 1)
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
PI
N
there 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 pri we or public water?
If private wel , 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 septic or public sewer?
Reviewer to complete the following:
Square footage of Use:
Y/N
Permitted as:
Under Section:
Supplementary regulations section:
Parking formula:
Required spaces:
YIN
Items to be verified in the field:
YIN
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit # Inspector
YIN
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
joning to com
Violations:
Y / r1C1
If so,Ist:
Variance:
If / i
If so,�+4 ist:
Clearances:
the
Date:
Notes: 4
i
Proffers:
Y�1;ist:
Ifs
SP'
Y
If so, List:
SDP's
Revised 1 Ill/2015 Page 3 of 3