HomeMy WebLinkAboutCLE201700146 Application 2017-06-27Application for Zoning Clearance
CI.,E
'q
OFFICE USE ONLY
PLEASE REN IF W ALL 3 SHEETS 1 Check # Date:
Receipt #
PARCEL INFORM
Tax Map and Parcel:. ? l) C 1 1 J
�.� � t<:xisttng tartan
f`�
Parcel {)weer:et
.4..1__i
Parcel Addressr -C} v C15`t iCitya� �(
i lk-. .______ to or or) _..... � tF lztw ��1 � � State ... _.._.V ._-_______ Zip ---
........... .-_.... .. ................
W ho should we cali,evrife concerning this project?
Address, jCitYYkI`�`W State Zip
Office Phone; �61Q,13 9`J e.St # Fax 4 _ � E-mail
...w._...r._..........._.,_.....�...._.......................... . ............... _ _..,_....._
A�'I'LIC�.�d T t�'Is"tC3i�'`I(3N
t heck any ss that ap0v- "hav e of ownership Change of use Change of name ✓ Nc`v business Mn _ _ sine__
Rusiness Nsrnefrype:
Previous Business on this site u ( Cw
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-,
...__. __...
fr3, C'earar;ce. will oniy be valid on 't e parcef for lwhieh it is approved. 1f you change, intensify ar move thu ,< :.ir a nev, location, a nfsw Zon.ng
Clearance will be requir;d.
I hereby certify that I own or have the o is 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 k dge, I have read the conditions of approval, and I understand them; and that 1 will abide by them. #
S gnaturc m. _. Printcd +`
. F"EROVAL 1,NFO"IATI
] Approved as proposed r I Approved with cnnditions [ j 11
1?ct ie
j 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.
Building Official Date
Zoning Official Date
Other Official Date
County of Albemarle Department or Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 F'ax. (434) 9724126
Revised 11/1/2015 Page 2 of 3
......... __ _._ _-- ...-....
Intake to complete the following:
Y�
Is use in Ll, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
W It �Mervbe food preparation?
ffso, 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 0
public water; ✓
Ifprivate weil, provide °ar ,;p;aw ent fore.
2.onirg review can i,rt begin unti', we receive approvzl from, health
Dept. FAX DATE
Circle the one that appliea j
Is parcel on septic or r bhe sewer:
Y t
'Kill you be putting zap a new sign of any kind? If so, obtain proper
Sign permit.
Permit 9
Y
Will t ere be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Reviewer to complete the following -
Square footage of Use:
�Y/N
Permitted as:_.
Undcr Scction:
Supplementary regulations section:
Parking formula
PUquired spaces:
Y11 N
Iterns to be verified in the field:
Clearances: j SDP's
Revised 111112015 Page 3 bf 3
v
0 4-
(3)
Cr LL
V)
N
O
N
m
v`
N
c-I
rl
O
Q�
N
N
Q
v
O
L
U
E
O
O
w U)
N
Ln
clf ,--1
O
O
O
C �
O L __
� c�
Ul) 0 c
m
ULn
-