HomeMy WebLinkAboutCLE201700061 Application 2017-03-10Application for Zonin ClearanceE
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PLEASE REVIEW ALL 3 SHEETS
OFFICE U E ONLY /
Check # J kS Date: 3 l
Receipt # D Staff:
PARCEL INFORM ON
-[-)C
Tax Map and Parcel2M�--CO -�/ —,.1 Existing Zoning t�('1
Parcel Owner:
ParcelAddress:10-0 WVanhP-ovk DP_IyL City rAAt2j,)4,4yj I l_ Statey�} ZipZ� !®f
(include suite or floor)
PRIMARY CONTACT i> D
Who should we call/write concerning this 1,4y- SYw 3y - 9(00 —
project?
Address: r1 City 6a) Vi 1 fJState \IA- ZipZZ � 2
31fj 7 C� �i "�Y c
Office Phone: �—' Cell # y�,,fJ=%�'c}9 Fax # E-mail S h tti►cc�kQ- -M
APPLICANT INFORMATION
Check any that apply:^ Change of ownership Change of use Change of name V New business
Business Name/Type: & bLi MCI SS (-A f-
Previous Business on this site U r-v q H
Describe the proposed business including use, number of employees,,number of shifts, available parking spaces, n mber of
vehicles, and any additional information that you can provide: uv_", M fL - dGh{ } m�e
2 C
) p,.AA1. " A c+ eta 1 \I-t
*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 �Qt� M C l,� {�X2t_.ti� Printed -�-� Ir.�F-jj Cle'a ��l�—e S�N V,M ST.
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, 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 i Date
Zoning Official Date
Other Official Date
t-ounty of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (434) 972-4126
DILI
Revised 11/1/2015 Page 2 of 3
Intake to complete the following:
Y / O
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y � Wi r-t#rE e 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 o public water? ,
If private well, provide Hea ment form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that appl'
Is parcel on septic public sewer?
Y N
Wil u be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit#
Y,r'
Will e 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: ' 5
Y/ N
Permitted as: AA �Q i�( 2uh I -,P—
Under Section:
Supplementary regulations section:
Parking formula:
�w TJ
Required spaces: --7
5
Y/N -'
Items to be verified in the field:
Inspector : Date:
Notes:
Violations:
Y/,6
If so, List:
Proffers:
Y/iCT
If so, List:
Vari ce:
Y /
If so, ist:
SP's:
Y /
If so, List:
Clearances:
SDP's
Revised 11/1/2015 Page 3 of 3