HomeMy WebLinkAboutCLE201600289 Application 2017-01-17Application f r Zonin Clearance"
CLE # C IL
PLEASE REVIEW ALL 3 SHEETS
OFFICE USE ONLY
Check # C Date:
l
Receipt # Staff:
PARCEL INFORMATION
Tax Map and Parcel: }�� j Existing Zoning_�5�
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Parcel Owner:
Parcel Address: 5,� �� `j , IY�'tO (�i z � City � r'i 2�� State k
Zi
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project?
S
Address: � �w�h��►h6 ' POrM 6 CA City Statey Zip
OfficePhone: () �-��� Cell 3y��d7�
ax E-mail SJ Mt S5
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APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name
ew business
Business Name/Type: �U S. G e- .� • Luw c+ (�
Previous Business on this site 1 2 4u
Describe the proposed business including use, number of employees, numberr� of shifts, available parking s aces,
number af.
vehicles,//and any additional informationthatyou can provide: '
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4S t7lG� )
*irance will only be valid on th arcel for which it hs Cleais approved. If you chan , i ensify 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 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
APPROVAL INFORMATION V
Approved as proposed [ ] Approved with conditions [ ] Denied
[ ] Backflow prevention device and/or current test data needed for this site. Contact ACSA, 977-4511, xI 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 i P % 1 'Z
Date ZZI 7
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: I Reviewer to complete the following:
Y / Ib Square footage of Use:
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet. ( / N
Y / I�
Permitted as:
Will there be food preparation? Under Section: 2 ,
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 applies
Is parcel on private well or ub is w er?
If private well, provide Health artment 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 sew ?
Y/N
Will you be putting up a new sign of any kind?
Sign permit.
Permit #
Parking formula: /
i
Required spaces:
Y1N
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:
Violat' ns:
Y //I
If so ist:
Proffers:
Y /
If so, t:
Vari e:
Y/
If so, 'st:
SP's:
Y/
If s��St:
Clearances:
SDP's
Revised 11/1/2015 Page 3 of