HomeMy WebLinkAboutCLE201700001 Application 2017-03-01Application for Zoning Clearance
CLE #�
OFFICE U Y
PLEASE REVIEW ALL 3 SHEETS
Check # Date:
Receipt # Staff:
PARCEL INFORM r
/1-7y
Tax Map and Parcel: "(� -C�n� Existing Zoning
Parcel Owner:.0,PQ"h+_W(AJ Wflmk; 110 -
Parcel Address:u 0 City omiState Zip
6—
(include suite Pr tl oor)
4/
PRIMARY CONTACT
Who should we call/write concerning this project? � (_ 776E:I�A 11AiP_Ur
Address: Z1 � (74Q ASS tAl >- L /J City 12 (-, Z.`E' T�Sttatte I ZA_ Zip -
Office Phone: C ... ) Cell # ` — Fax # E-mail�lh(
�D(eq [A l.
� 1 C6rVl
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name v," New business
1
Business Name/Type:
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 : LAZJJ D -F_ -t
APPROVAL INFORMATION
[ Approved as proposed [ ] Approved with conditions [ ] Denied
[ ] Backflow prevention device and/or current test data needed for this site. Contact ACSA, 977-4511, xl 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 Date
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 11/1/2015 Page 2 of 3
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.
4/ N
ill 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 wellpublicwater�
If private well, provide Hea t tment form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applies
Is parcel on septic u lie sewer9
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, obtafg opgr a it.
Permit # \
Zoning to complete the following:
Reviewer to complete the following:
Square footage of Use:
0/ N
Permitted as: i re`s
Under Section:
Supplementary regulations section:
Parking formula: /
Required spaces: /
Y/�
Items to be verified in the field:
Inspector : Date:
Notes:
Violations:
Y/A
Ifs , ist:
Proffers:
Y/N
If so, List:
Variance:
Y/UI
If so, List:
SP's:
O/N
If so, List:
Clearances:
SDP's
Revised 11/1/2015 Page 3 of 3
Application for Zoning Clearance
CLE #
OFFICE UI
Y
i I PLEASE REVIEW ALL 3 SHEETS Check # Date;�
Receipt # Staff:
PARCNFORMATI
Tax Map and Parcel: ��% { -� Existing Zoning'�/�_.[ J� ;
Parcel Owner:
Parcel Address:-4.rs City �� State_ Zip
uit
(include se r oor.
PRIMARY CONTACT _ _ _
Who should we call/write concerning this project? % �_ (l /.� � ��� �� .
Address �y,�Cl`�` f,! Y- 1\! City �, `f r State //- .7 Zip '.
Office Phone; { �) Celi # `G�C� `i^j Fax # E-mail
APPLICANT INFORMATION
Cheep any that apply: Change of ownership Change of use Change of name New business
Business Name/7'ype: C1 C_'[� 't: 12�j i(�- _ `�,pirlu� �i C S .1010:-77
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. 1 also certify that the information provided
is true and accurate to the best of my knowledge. I have read the conditions of approval, and 1 understand them, and that I will abide by them.
Signature S' t: _ Printed
APPROVAL INFORMATION
[ J Approved as proposed ( J Approved with conditions [ J Denied
[ ) Backflow prevention device and/or current test data needed for this site. Contact ACSA, 977-4511, xl 17.
( J 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
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (434) 972-4126
Revised 11112015 Page 2 of 3