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HomeMy WebLinkAboutCLE201800207 Application 2018-10-04A Linn,-,% . r', P . -7;15156 " 3( ApplicatiQq earance/' i C# ' if' PLEASE REVIEW ALL 3 SHEETS OFFICE USE ONLY Check # Date: Receipt # Staff: PARCEL INFORMATION _ PV" Tax Map and Parcel: Existing Zoning IM 1 - Gorn� Parcel Owner. r �{- / a �7 Parcel Address: 3© 2-4iLk_M0-t1 City I.t 11.QS V 11. ate U Tl Zi /2 j J P (include suite or floor) PRIMARY CONTACT L / Who should we call/write concerning this project? /4 . Address • 1 Q i . ( City 5a40 511 �to V Zip 9- 7:2-1 O Office�l[e e: �) ..Cell # �0 `7ax # E-mail , W dSao� to �J APPLICANT INFORMATION Check any that apply: Change of Change of use Change of name New business +owne'rship` ( Business Name/Type: Previous Business on this site N A Describe the proposed business including use, number of emplo es, numbel of shifts, available parkin spaces, number of 1 vehicles, and any additions nformation t tyou ca provide: ✓DPI-/� 10- *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 that I own or have the owner's permission to use the space indicated on this application. I also certify that the information provided d I understand them, and `that rI ill abide by them. is true and accurate to the best of my knowledge. I have read the conditions of approvro Signature Printed APPROVAL INFORMATION [ ] Approved as proposed f ] Approved with conditions [ ] Denied [ ] Backflow prevention device and/or current test data needed for this site. Contact ACSA, 977-4511, xI 17. [ ] 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 f0 Z47)'� ,zoning Official Date i 0 C, r Other Official Date County 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: Is Nn LI, HI or PDIP zoning? If so, give applicant a Certified Engineer's Report (CER) packet. Wz*"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 publ c wa If private well, provide Health artment 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 c se \. Y/N Will you be putting up a new sign of any kind? Sign permit. Permit # If so, obtain proper 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: ot✓ Y / N�� Permitted as: Under Section: Supplementary regulations section: Parking formula: Required spaces: Y/N Items o be verified in the field: Inspector : Date: Notes: Vi ns: Y If so, ist: Proffers: Y /,-'Iv 1 If so, tst: Variance: Y /(N) If so, ist: SP's• Y If so, List: Clearances: SDP's "l q4 9 Revised 1 I/l/2015 Page 3 of 3 CERTIFICATION THAT NOTICE OF THE APPLICATION HAS BEEN PROVIDED TO THE LANDOWNER This form must accompany zoning applications (Home Occupation, Zoning Clearance, Zoning Administrator Determinations or Appeals, Sign Permits, Building Permits) if the application is not the owner. I certify that notice of the application, was provided to [County application name and number] [name(s) of the record owners of the parcel] and Parcel Number manner identified below: Hand delivering a copy of the application to the owner of record of Tax Map by delivering a copy of the application in the [Name of the record owner if the record owner is a person; if the owner of record is an entity, identify the recipient of the record and the recipient's title oM�� that entity] on 9 Date ® Mailing a copy of the application to [Name of the record owner if the record owner is a person; if the owner of record is an entity, identify the recipient of the record and the recipient's title or office for that entity] on Date to the following address: [address; written notice mailed to the owner at the last known address of the owner as shown on the current real estate tax assessment books or current real estate tax assessment records satisfies this requirement]. Signature HApplicant Print A licant�1,8 ame 711 Date