HomeMy WebLinkAboutCLE201600252 Application 2016-11-21! Application n Clearance ull-v`
OFFICE iJ ONLY
PLEASE REVIEW ALL 3 SHEETS'heck A A7 Date:
_....... 11�eceipt i� Staff.
EL I YFOR ATIO
Tax Map and Parcel: _.._.. (k� ` V5 - 1 existing Zoning
Parcel Owner: 1' � �rr D l� .'/
Parcel Address:__2k d 1 l 4 e, City d � �y� � 1 � Zip
(include sil tt e or floor) t ✓t✓C t -.........—._ ,
PRIMARY CONTACT , ` N
Who should we call/write concerning this project' ##� '1_'-t4 � 1e)
Address; ��( d✓ tt'c city C6,ar1e1te,w1fSt1t1 Zip �-�
Office Phone: q ��
Fax 4 < -mail
A.PP :IC'AN` ' IN `OR ATION
Check any that apply: -Z,-- Change of ownership Change of use Change of name New business
1lusiraessianae?"f�pc.�,;G'"t- S� •r,.'�/cc� ,1 f�_d.`�/ '" f'iX�1li� 1��7A�LQ1i'Jl%S�
Previous Business on this site
Describe the proposed business including use, number of employees, number of shifts, available parking spaces, number f
vehicles, and any additional information that you can provide: C7 "ZCJ G�� O� ✓¢ 13R1
his ........
learance will only be valid or: the parcel for which it is approved If you change, intensify or move the use to a MW ioeatian, aXewZoaing
Clearance will be required.
1 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 knowledge. I have read the conditions of approval, and i understand them, and that I will abide by them.
Signature � I/
Printed_
APPROVAL INFORMATION
$P4 Approved as proposed [ ] Approved with conditions [ ] Denied / n� „J
[ ] Backflow prevention device and/or current test data needed for this site. Contact ACSA, 977-4511, x117. — (jrGc ( -+Q
1 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 ( -z
Zoning Official ---- - Bate
Other Official Bate
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 "nice: (34) 29 -5832 Fax, (434) 972-4126
Revised 11/1/2015 Page 2 of 3
le-c-
,1-0, -n �-
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.
°c
Will there be food preparation? l
If so, give applicant a Health Department form.
Zoning review can not begin until we receive approval fmm health
Dept. FAVDATE
Circle the one that applies r
Is parcel on private well or fs lslic w:et
If private well, provide Health ent form.
Zoning review can not begin until we receive approval from Health
Dept, FAX DATE
Circle the one that appli
Is parcel on septic a ublic sews .
7N
Y / N,
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y /
Will�tere be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
'7-3— k-.,, .,tit, fhs fnly-IA,;n am
Reviewer to complete the following -
Square footage of Use:? "
Y/N
Permitted as:
Under Section:
Supplementary regulations section:
Parking formula:
Inspector -
Notes:
....._--- ...............................--- ... _....... _
'Violations.
Y/N
If so, List:
.Proffers:
Y/N
If so, List:
klariance:
Y/N
If so, List:
SP's:
Y/N
If so, List:
Clearances, _
SDP's
i
Revised 11/l/2015 Page 3 of 3
n
3
N X.
'p 0
O0O"0CD
C
_ a
�'�CD
CA)
io
cl)
W
n. W
D
;r*
CD
p
O
N
C
�
Q to
n
N
O
O
N
O
00
N
O
Cn
N
O
A
N
O
w
N
O
N
N
O
N
O
0
O
0
O
Cn
O
A
O
W
—
O
N
O
O
O
a
w
n
m
a
CO
O
N—
w
CO
N—
w
Cn
W
O
N
A
N
1
W
-•
N
Cn
A
to
w
N
A
00
0
K
00
CC)
A
Cn
-Al
m
W
J
O
Cn
O
00
O
N
N
mmc)c
0 ET = a:
I
n
(p to ; :
`moo°
v
N
O
O
00
O
O
00
O
CD
O
0
3
.�
�
o
0
0
0
CD
0
3
(D (D
Or
lD
CD
fD
lD
lD
(D
fD
(D
a
M
=
fD
y
N �'
*
(D
(D
(0
D
CD
cu
CD
ni
a w
(J
T
. . .. ......... ..