HomeMy WebLinkAboutCLE201800222 Application 2018-10-31jPPROVEr
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Application fo ZoningClearance �1""`1�,
CLE # O�oZ ,,�1
OFFICE U ON Y
PLEASE REVIEW ALL 3 SHEETS
Check # Date:
Receipt # 7 Staff:
PARCEL INFORION
Tax Map Parcel:M C)L ' � b ®
and lm Existing Zoning
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Parcel Owner:
Parcel Address: 9'l U k L1 ► tl.t / �'1 t City C&AM Wvi ktateyG Zip
(include suite or floor)
IMARY CONTACT
o should we call/write concerning this project9 rof�- h
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Office Phone: Cell # DI(y5wgFax # E-mail (' veJOZ ill/
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name/Type: _ _Solo Q
Previous Business on this site
Describe the proposed business including use, number of employees. number of shifts vailable parking spaces, number of
vehicles, and any additional information that you can.pr, ide:
A I( a S -
*This Clearance will only) be valid on the parce for which it i pproved. 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
is true and accurate to the best of my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature Printed
APPROVAL INFORMATION
[ ] Approved as proposed [ ] Approved with conditions [ ] Denied
[ ] Backflow prevention device and/or current test data needed for this site. Contact ACSA, 977-45 11, x 117.
[ ] 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 l
Other Official Date
t-ounty of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (434) 972-4126
al
r
Revised 11/1/2015 Page 2 of
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 /fo
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 on ' s
Is parcel on rivate well r public water?
If private well, prove e ealth Department form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that a ies
Is parcel on septic Tr public sewer?
Y >�
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y
WilQtere be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
ZoninLy to complete the followin
Violations:
Y/N
If so, List:
Var' ce:
Y ,
If ist:
Clearances:
QOj (.2
9 n,;,H a R_ 1 5�
12b)1- 9A
ar»a — fi�% 4 z%.)1%
Reviewer to complete the following:
r�Square footage of Use:
Y / N (c)
Permitted as.
Under Section:
Supplementary regulations section
Parking formula:
Required spaces:
Y �,enfied
Itethe field:
Inspector :
Notes:
Date:
Pro
Y N
If o ist:
SP's:
Y / N
If so, List:
SDP's
0-
Revised H/1/2015 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, �! a 6 ;� 3
[County application name and number]
was provided to
[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 or office for that entity]
on
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].
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Signat re of pplicaM'
Print Applicant ame
cv 1 `7 I
Date
0' 1: `"
89tillva@gmail.com
2015--04--30