HomeMy WebLinkAboutCLE201700138 Application 2017-06-09Application for Zoning Clearance"
CLE 4�
OFFICE USE 9NLY
PLEASE REVIEW ALL 3 SHEETS Check # M10 Date:
Receipt # Staff:
PARCEL INFORM/� Tj O i M
Tax Map and Parcel: —V-6_� Existing Zoning�C
Pa reel Owner: ffi 61K �4WA►M. I fM4,'), 1 1,1y
111 tlU\I[h . I
Parcel Address: City State Zi
(inclu6 suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project? ,r*
Address : �i {( -pt' n r.2ps l city l . y-a-1 cksyikst,t, J.6 Zip ;_72CW
Office Phone: (� fily ��ell # �i -��" _ LL`��� Q(C' %5
'1-ZLe E-mail ICE kSCly)JC,e(:f1I f'CitiJ(>.et?�,t
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New, business
Business Name/Type: �SCtCt<,SC�Y'�� IIo-nI (I J Ili co_ U— �° SR1re y 7ey iC_i
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: a. •; 2n} ( . .lam -E ire 5n I f t
%3 is _hicim ��,.. _r
"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 1 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.
Signatur ".,.� �f �4i1lt N ' osln I
�� � Printed �} 1%t''ta�
APPROVAL INFORMATION
[ICJ Approved as proposed [ J 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 Officia Date 6P -7
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/]/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.
Y �te)re
Will 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 public 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 public sewer?
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Reviewer to complete the following:
Square footage of Use: _` 2 DJ
(9 / N
Permitted as: �,»,�✓Vtw /reAl
Under Section:
Supplementary regulations section:
Parking formula:
Required spaces: S
Y /,A}S
Items o be verified in the field:
Inspector:
Date:
69/ N
Notes. -
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the following:
ro ffe
Yi /lations:
)
If so, List:
IIYf/so, List:
s—
Variance:
s;
O/ N/
N
If so, List: �
s-
If so, List:
Q
9 SS'
Clea rances:
SDP's
U �l-
-�9.1-
434
Revised l I/1/2015 Page 3 of