HomeMy WebLinkAboutCLE201700122 Application 2017-05-23Application for Zoning Clearance
CLE # 20I + - �'2Z
PLEASE REVIEW ALL 3 SHEETS
OFFICE U E f ]NLY
� C..�• Date: (�-
Receipt '� Staff: _
PARCEL INFORMATION),/� �j�
p
Tax Map and Parcel: �p'' �� Existing Zoning V IAC_
Parcel Owner: rn, h U (Yf_ i o d �04AUKn r n
Parcel Address: GS �.l�<M(,�r lQ { � City r Il V,l State ZjP
(include suite or floor)
PRIMARY CONTACT _
Who should we call/write concerning this c ✓�`,kig �)'Iczf
spproject? )U,
Address : i,��� � j1 j� C� i�,_f lea City (— . 5W 112 . State VA Zip
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Office Phone: �) Cell #434 _ ,j4,'1-4'�¢Fax # E-mail
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name/Type: Middlij , n GCj— j�5,
i -
Previous Business on this site 1 , L i kkf q
Describe the proposed business including use, number of empl ees number of shifts, available arking spaces, number of
vehicles, and any additional information that you can provide:
S UOLS
*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.
Signa i A Al PrintedMM���� f��f
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, xI IT
[ ] 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
Date
Date
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (434) 972-4126
Revised 1 ]/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
Wil�thre 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 or .Qublic water
If private well, provide Health'Depariment form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applies
Is parcel on septic o�bliic .
Y)/ N
mill you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Reviewer to complete the following:
Square footage of Use: 7y0l'D
Y/N y
Permitted as:
Under Section: 2 `.
Supplementary regulations section:
Parking formula: J
�' � sY, tt
Required spaces:
Y /
1te to be verified in the field:
Permit # Inspector : Date:
Y ; NN- Notes:
Will —Mere ere be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the followin
Violations:
Y / �I�Tj
If so, ist:
Proffers:
Y / l�
If so, List:
Variance:
Y/
If so, ist:
SP's:
Y/
If so, List:
Clearances:
SDP's
Revised 11/1/2015 Page 3 of 3
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