HomeMy WebLinkAboutCLE201700184 Application 2017-08-27Application for Z® ing clearance
CLE #
OFFICE* tiff ZY
013
PLEASE REVIEIVV ALL 3 SHEETS Check # Date:
Receipt N — Staff
PARCEL INFORNtATION
Tax Map and Parcel:rJ
Parcel Owner: (1%u % as
Parcel Address: h�ftm A ______ City State V p Zip
( ttuite or, floor)
PRIMARY CONTACT J �
Who should we call/write concerning this project?
Address: (LS 2 Z ity C� `e___ State 71p Z Zfj 3
Office Phone: Cell # `i3� `� • V;Z # E-mail �"�k V4iM,1Ak 1-49 gMar
cam
APPLICANT INFORMATION
I Check any that apply: Change of ownership Change of use V Change of name New business
BusinessA'ame/7'ype: kgEMJJAffla=
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:
•This Clearance will only be valid on the panel for which it is approved. If you change, intmsity or move the use to it new location, a new Zoning
Chmrance will be required.
hereby cenify that I uwnt or- have Iite ow ner's trermissiIII to use the space indicated on Ili is application. I atsu ccnify that the ini'onnation pmvidctl
k true and accurat t t kst nl'my knowledge. 1 huvc rwd the conditions of approval, and I undListand them, and that 1 will abide by than.
Signature _ ��) Printed H1%n-k
APPROVAL. INFORMATION
Approved as proposed ( ( Approvrd with conditions ( j Denied
Backflou• prevention device and/or current test data needed for this site. Contact ACSA, 977.451 I, x 117.
( j 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:
'Il
Building Official f✓xi( Date ��--,,-�� ^�
Zoning Official Date 11-
Other Official A/XA_ ! 'oV1, 5f.4 L/J!/IJV Y Date
County of Albemarle Department of Community Develop
401 McIntire (toad Charlottesville, VA 22902 Voice: (434) 296-5832 Fum (434) 972-4126
Revised 1110V2015 Page 2 of 3
Intake to complete the following:
Y / 1�
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
VY/N
ill 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 is water?
If private well, provide Healt --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 iF s9Wer?—
Y/0N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y/
Will ere be any new construction or renovations?.
If so, obtain the proper Permit.
Permit #
Zoning to complete the following:
Reviewer to complete the following: f
Square footage of Use: C
6 / N /
Permitted as:�
Under Section: Z -5�,d , 2
Supplementary regulations section:
Parking formula: �-6J
Required spaces:
Y/N
Items to be verified in the field:
Inspector:
Notes:
Date:
Violations:
Y/(V
If so, ist:
Proffers:
N
If so, List:
Vari ce:
Y/
If so, List:
SP's:
I'/N
If so, List:
6 �� 0
Clearances:
SDP's
6 7-
0s
3a
Revised I 1 / ] /2015 Page 3 of 3