HomeMy WebLinkAboutCLE201700173 Application 2017-07-28Application for Zoning Clearance
CLE #6?6ja -
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OFFICE U NL
PLEASE REVIEW ALL 3 SHEETS Check # Date:
Receipt # Staff:
PARCEL INFORMATION �
Tax Map and Parcel: C> 32a0 - 00.OD - 0 5'*Ai Existing Zoning hwlkj
Parcel Owner: 5 0 F \ A, 2'`i t..l. L
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Parcel Address:34sn ,�EMA\ r � L City t<.4I Zipz .11
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project? _i`'�A--(h10&'a-'D S"C->C
Address:[L6 G%1,.Vt..l,e-Tr City4A&nuE-%V-4•ttL. State QA ZIp?Z°loZ
Office Phone:` Cell # Fax # E-mail f'A4
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APPLICANT INFO TION
Check any that apply: Change, of ownership Change of use Change of name New business
Business Name/Type: 1) t '"iL_ 9A-;a XLaP�ct.S'T'
Previous Business on this site 15AYuA8
Describe the proposed business including use, number of employees, number of shifts, available parking spaces, number of
vehicles, nnd anx ndditionnaall Informntion that you can provide: S Ac N\E AA M t-Ylit%,L — hJCh
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'This Clearance will only be valid on the parcel for which it is approved. Ifyou 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 knowled e. ve read the conditions of approval, and I understand them, and that I will abide by them.
Signature Printed MAqF-1A4-%p
APPROVAL INFORMATION
[ ] Approved as proposed [ J Approved with conditions [ J Denied
[ ] Backilow prevention device and/or current test data needed for this site. Contact ACSA, 9774511, x117.
[ J No physical site inspection has been done for this clearance. Therefore, it is not a determination of compliance with the existing
site plan.
[ J This site complies with the site plan as of this date.
Notes:
Building Official Date
Zoning Official Date
Other Official Date 7 AZ1
County of Affiemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (434) 972-4126
Revised 11/1/2015 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.
v/N
Will there 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?
ater?
If private well, provide Hekth44qyArtment 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 pu lie sewe ?
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y/N
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the following:
Reviewer to complete the following:
Square footage of Use: ? $ ZS
J/ N
Permitted as: L. s4mcJ
Under Section: 2' /
Supplementary regulations section:
Parking formula: /3
00
Required spaces: //
Y lW
Items to be verified in the Feld:
Inspector:
Notes:
Date:
Violations:
&/ N
If so, List:
Proffers:
Y /c)
If so, List:
Varia ce:
Y/
If so, ist:
SP's:
CY)/N
If so, List: 4� J
Clearances:
SDP's
Revised 11/l/2015 Page 3 of 3