HomeMy WebLinkAboutCLE201700049 Application 2017-02-22Application for Zoning Clearance
y�``"`y
tt��
CLE #_olb&� n
i; F
�� ��r:
PLEASE REVIEW ALL 3 SHEETS
OFFICE E NLY
Check # Date: A -
Receipt # Staff:
PARCEL INFORM I Vv.
M
Tax Map and Parcel: (- - Existing Zoning D�
Parcel Owner:
Parcel Address:�jo O'td F_i STD City��1""`" ZTd Mate V rT �f
Zip
(include suite or floor
PRIMARY CONTACT
Who should we call/write concerning this project?
Address ° 99b P-113 4Lf-}S-t" City ��� State Zip 4
Office Phone: Ij(--�f ell # S(o(- Fax # E-mails
Csn(
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name/Type: t-4 d
Previous Business on this sitet ��"fi'[��! `� (SSCJ� • C�
Describe the proposed business including use, number of employees, number of shifts, available arking spaces, number of
vehicles, information
and any additional that you can rovide:
*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
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.
Notes:
Building Official !� Date
Zoning Official Date
Other Official Date
L:ounty 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 / 0
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y / th 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�blicwatt'If private well, provide Hertment form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applies
Is parcel on septic ubli�$r?y
U/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y/
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: �j J
4/N
ermitted as:
Under Section:
Supplementary regulations section:
Parking formula:
7 L2 J
Required spaces:
Y /
Items to be verified in the field:
Inspector : Date:
Notes:
Violations:
Y/(V
If so, List:
Proffers:
(Y/N
If so, List:
Vari ce:
Y/;
If so, List:
SP's:
Y/
Ifs , List:
Clearances:
SDP's
Revised l I/1/2015 Page 3 of 3
s
ry-)