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HomeMy WebLinkAboutCLE201700187 Application 2017-08-27Application for Zoning Clearance °A` CLE # PLEASE REVIEW ALL 3 SHEETS OFFICE USE ONLY Check # ('l Date: �'�(U 'l% Staff: Receipt # CL PARCEL INFORMATION Tax Map and Parcel: (2g5b Ub --ca 1. LL1z LD Existing Zoning areelOwner: ��1artate Zip Parcel Address:` City p� (include suite or floor) PRIMARY CONTACT , ka- Who should we call/write concerning this project? � e Address: 4 ©�,�Pz)Ale Or; city State Zip Office Phone: #2 9'713' Cell # � _13bly Fax # .� E-mail �owl APPLICANT INFORMATION Check any that apply: Change of ownership V Change of use Change of nameNew business Business Name/Type: daj—r40n'1 777erR eit7?,.-- CI`JW 10/?6-bA0 Iq g�nds a� �' ��Pr�>���G!y�%iy /%Sd�%�' 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 ca%provide: l S *This Clearance will only be valid on the parcel for which it is approved. If you cliange, intensify or mo 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 infonnation provided is true and accurate to the best of my knowledge. I have read the conditions of approval, I understand them, and that I will abide by them. /and Signature r Printed APPROVAL INFORMATION ] 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 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 ✓ Date��/d' Other Official Date County of Albemarle Department of Community Development 401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (434) 972-4126 �m Revised 11 /02/2015 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 / Will 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 is wate 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 Ic sew . Y /� Will you be putting up a new sign of any kind? If so, obtain proper Sign permit. Permit # Y / Wil re 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: IJ / N Permitted as: Under Section: Supplementary regulations section: Parking formula: Required spaces: G' Y / Items to be verified in the field: Inspector: Notes: Date: Violations: Y / V If sot: Proffers: Y / If so, ist: Varia e: Y/ If so, List: SP's: Yb4 If so, List: Clearances: SDP's Revised l l/l/2015 Page 3 of 3