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HomeMy WebLinkAboutCLE201700115 Application 2017-06-05Application for Zoning Clearance�A`' CLE #��- fi OFFICE US + LY PLEASE REVIEW ALL 3 SHEETS Check # Date: Receipt # Staff: PARCEL INFORMATIONp Tax Map and Parcel:C� �(� !�� - f7 (^ CSC - ©O .� A0 Existing Zoning Parcel Owner: Parcel Address: ,Tiu'S�re>�,c'� 41-y • City har/ ✓,:�� State L ll'Y Zip o5'// (include suite or floor) PRIMARY CONTACT Who should we call/write concerning this project? J T-eLe Pkkp� 1- Address: % S3,Z hS L�ti r> C < h 2 City Q-144 r eJi"%'tate Zip / Office Phone: 1 N -9i 6.2- Cell # 3�! Z S -!GG 7 Fax # 17`/ ` 7S�S E-mail S% ee zaIl5T� APPLICANT INFORMATION Check any that apply: Change of ownership Change of use Change of name ✓ New business Business Name/Type:-7SS -.,u.,.r.ce Lalce--\- 4i o,4e a f+rrA L i C (4Har�2Er5 lhs .,, Previous Business on this site cn- (lam� U-"l per` Describe the proposed business including use, number of employees, number of shifts, available arking spaces, number of vehicles, and any additional i for ation that you can provide:V. 0 L f ¢ (t. .Zr e , r� d'✓Li E� E' LiQ t'�ksi hE'�S IL�i2 vP is *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 accu e t the be of my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them. Signature 1���. /'�l cot Printed StE p �f» � • k� AP OVAL INFORMATION [ Approved as proposed [ ]Approved with conditions [ ]Denied [ ] Backilow 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 6 Date14 Other Official Date 1-ounry of .vnemarie Department of Community Development 401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (434) 972-4126 Revised 11/02/2015 Page 2 of 3 Intake to complete the following: Y/(D Is use in LI, HI or PDIP zoning? If so, give applicant a Certified Engineer's Report (CER) packet. Y / nN Will t 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 or ublic water? If private well, provide 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 septic or ublic sewer? Y/N Will you be putting up a new sign of any kind? If so, obtain proper Sign permit. Permit # Y /a Will t ere be any new construction or renovations? If so, obtain tbQ proper Permit. Permit # a Zoning to complete the following: Reviewer to complete the following: Square footage of Use: 1 -72- F Y/ermitted as: ors Under Section: o Supplementary regulations section: Parking formula: Required spaces: Y/N Items to be verified in the field: Inspector : Date: Notes: Violations: Y/N If so, List: Proffers: Y/N If so, List: Variance: Y/N If so, List: SP's: Y/N If so, List: Clearances: SDP's Revised 11/1/2015 Page 3 of 3