HomeMy WebLinkAboutCLE201600249 Application 2016-11-17Application for Zoning Clearance
CLE #
OFFICE USE ONLY
PLEASE REVIEW ALL 3 SHEETS Check # &S�k _ Date: -j I
Receipt # 2 Staff: )�
PARCEL INFORMATION
Tax Map and Parcel: Existing Zoning
Parcel Owner:
Parcel Address: 1 I (j ity C 1CtI �p�SU State W Zip
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project? _QSuCt uer-on i rr, Lrbfon
Address: as ar, R' (L V1 4 City PLW) Wbr) State V/-/
Zip
Office Phone: ( (o Cell # Fax # E-mail Ze r'ogrLvt tiee 1
APPLICANT INFORMATION
Check any that apply: -fir Change of ownership I)Change of use Change of name ✓ New business
Business Name/Type: C-C Ko G r6l V i Z j —Ids Q
Previous Business on this site
Describe the proposed business including use, number of employees, number of s ifts, available arking spaces, number of
vehicles, and any additional information that you can provide: �(� c r•1 c �%m� aF iL, 4J 1Ca jee,
� Sh,{'t
*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 permission to use the space indicated on this application. I also certify that the information provided
is true and accurate to the best of my kn aarle e. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature Printed Sas u ✓ l�bi U'1
APPROVAL INFORMATION
pt'] 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.
Notes:
Building Official Date l t
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/]/2015 Page 2 of 3
CO
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 /I�
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 pu 6iewa
If private well, provide 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 p�er?
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Reviewer to complete the following:
Square footage of Use: , CO
X/N /
Permitted as: / v,�o� elA k C /
Under Section: Z , ; '% ,
Supplementary regulations section:
Parking formula:
Required spac.es:
Y/1�
Items to be verified in the field:
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:
Viol ons: Proffe :
Y / Y /
If so, ist: If so, List:
Vari ce: P's:
Y/tg I /N
If so, List: If so, List:
Clearances: SDP's
Revised I1/1/2015 Page 3 of 3