HomeMy WebLinkAboutCLE201800228 Application 2018-11-20Application for onin Clearance_��°yy
CLE # O
•. � �RGINIP
PLEASE REVIEW ALL 3 SHEETS
OFFICE US + ONLY
Check # Date: 1 0 ' 31. 1
Receipt # 1 1rj"7 � 7 Staff:
PARCEL INFORMATION
Tax Map and Parcel: ���� �'flfl - OQ — 4I�'(� Existing Zoning�1 —C 0�111I�1PX
Parcel Owner: `Y V 0C)m L Jk(')
Parcel Address: \� �� City C1�t 01 ate Statey
Zip�b1
(include suite or floor)
PRIMARY CONTACT ,
Who should we call/write concerning this project? U1
j _L+'
Address : J � �OtidOr�l� �'� City �-t01T� i State
Zip
Office Phone: ( ) Cell # Fax # E-mail 00I A$
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name/Type: (AS C . 0,65 Q vn a n '
Previous Business on this site
Describe the proposed business including use, number of employees, number of�shifts, available parking space number of
vehicles, an any additiona infor that yoV can rovide: — ( e oA a
_IVC(Klw� ,S
11u
0 .t'on
- i t
H-0
*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,
Clearance will be required.
a new Zoning
I hereby certify that I own or have the own 's permission to use the space indicated on this application. I also certify that the information provided
is true and accu the best of my edge. I have read the conditions of approva and I understand th and that I will abide by them.
s
Signature Printed 1.�_l
APP 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
Other Official Date
-.1a ' ul CurallC JJCYdrLlnent oI l:ommunity LQvelopment
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:
Y /(9
Is use in LI, HI or PDIP zoning?
Engineer's Report (CER) packet.
If so, give applicant a Certified
Y /
Wil re 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 wat
If private well, provide Heal ment form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applie
Is parcel on septic or pu 'c sew
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:
qa
Y/N�
Permitted as: n j^
Under Section: a O� . �. �►)�
Supplementary regulations section:
Parking formula: YkA,
(Mir\ 11-�Medu,
Required spaces:
Y/N
Items to be verified in the field:
Inspector : Date:
Notes:
Vio io s:
Y
If so, List:
offers:
Y/N
If so, List:
ariance:
Y/N
so, List: q
SP's:
y/�
If so, ist:
Clearances: a
y _ I
SDP's ` �0 _ /� Ow"
l
' _I
6
-N7
164, Revised 11/1/2015 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) f the application is not the
owner.
7
I certify that notice of the application,
- [County application name and number]
was provided to W DO tl10CDID V_ kZbb (It � l�� the owner of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number W90b-0*0 -00 —`D 01 C Q by delivering a copy of the application in the
manner identified below:
Hand delivering a copy of the application to Acce,u
Pco�RA-c
[Name of the record o er 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 110 �Qjq
Dat
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 to the following address:
Date
[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].
Fee Received
�16_0
Received D to
Receive
10/ IQ I Al�
Date