HomeMy WebLinkAboutCLE201700175 Application 2017-07-27Application for Zoning Clearance
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OFFICECLE
�.Y
PLEASE REVIEW ALL 3 SHEETS
Check #SE
Date: ! 1l
Receipt # Staff:
PARCEL INFORMAT„IQN
Tax Map and Parcel: '�� li-o _��_ Existing Zoning CA
Parcel Owner: Lmja+U
Parcel Address: jqn (,4 4 City .-�a JIle—State �J Zi p
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project? ��� ✓�f=aU J 1C,i}�
Address: 496 t &TIALM6,� I Cityd4ja t ' St dje State VLL Zip da-90l
Office Phone: U Cell # ` 434q&7-0i41 Fax # E-mail `ka/.. A.111eJI-61F j t1rC.
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name w business
Business Name/Type:
Previous Business on this site
Describe the proposed business including use, number of employees, number of shifts, availa parking spaces, number of
vehicles, and any additional information that you can provide: h!�q
*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 t t I own or hCvethe o er's pennission to use the space indicated on this application. I also certify that the infonnation provided
is true and accur e to the est owledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature Printed
APPROVAL INFORMATION
X 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 deterinination of compliance with the existing
site plan.
[ ] This site complies with the site plan as of this date.
Notes:
Building Official � Date
Zoning Official Date 712- i 7
Other Official Date
Lounty of Albemarle 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�
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y/N
Wi re 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 r p
ublic
If private well, provide Hea tm.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applie
Is parcel on septic r public sewer?
Y /) N
ill you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
FEM N
F761 there be any new construction or renovations?
If so, obt 'tWr it
Permit #I n"
Zoning to complete the following:
Reviewer to complete the following:
Square footage of Use: J�
61N Permitted as: �J//
(-"A f 4 S
Under Section: 22 ;2 ,
Supplementary regulations section:
Parking formula: A
�a -1
Required spaces:
Y/
Items to be verified in the field:
Inspector : Date:
Notes:
Violations:
6 / N
If so, List: 1
Proffer :
Y/Ny
If so, List:
Variance:
(t/ N
va
If so, List:
662
SP's:
Y /O
If so, List:
Clearances:
SDP's
it- 4!
Revised 11 / 1 /2015 Page 3 of 3