HomeMy WebLinkAboutCLE201600281 Application 2017-01-03Application for Zoning Clearance
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CLE # r2pJLa- 0�1
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PLEASE REVIEW ALL 3 SHEETS
OFFICE USE ONLY
Check # 2ASh Date: 1'Z %
Receipt # Cf Staff:
PARCEL INFORMATION `� ``•
Tax Map Parcel: i
and Existing ZoningC
Parcel Owner: A
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Parcel Address: � 4 I S6 J aChOft P TI 26 City ( 61(0'eS1/We, State VGA Zip ?2 .;
(include suite or floor)
PRIMARY CONTACT V p�
Who
should we call/write concerning this project?
City �LW (%+[eJ ul�!!e- State (�} Zip 29- u
Address: 3 ) j Tl Aen 6Yat''``�pD
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Office Phone: (� Cell # 4-c3) 713o Fax # E-mail C X381
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
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Business Name/Type: Ac!ym ttwf_ Chahl fte _(n�_CQ,tP�r
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 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 Printed
PPROVAL INFORMATION
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�5--
Zoning Official IVY Date jf��17
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Other Official V 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 /
Is usMh LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
WINE
Will 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 private well - is ter?
If private well, provide Hea partment form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that apffbl
Is parcel on septic ore ?
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, obtain the proper Permit.
Permit #
Zoning to complete the following:
Reviewer to complete the following:
Square footage of Use:
Permitted as: o Lei' U1�-�l cep
Under Section: 7_'L ,Z •'
Supplementary regulations section:
Parking formula: /
J
Required spaces: -�
Y/
Items o be verified in the field:
Inspector : Date:
Notes:
Violations:
Y / W
If so, List:
Proff s:
Y / O
If so, List:
Vari e:
Y/1
If so, List:
SP's:
Y /�J
If so, List:
Clearances:
SDP's
Revised 11/1/2015 Page 3 of 3
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