HomeMy WebLinkAboutCLE201900020 Application 2019-02-06 (2)APPROVE[:)
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Application for Zoning Clearance
CLE # ;3LL
PLEASE REVIEW ALL 3 SHEETS
OFFICE USE ONLY
Check# Date:
Receipt # ! Staff:
PARCEL INFORMATION
Tax Map Parcel: �(�� 6� �V '
and (DA Existing Zoning
Parcel Owner:_ K0M n —1 —i I L4j
Parcel Address: l �aan City State Zip �"I
(include suite or floor)
PRIMARY CONTACT
Who should we call/write ncerttin this poi ct? `��0� i10 ( A)
Address :� �j City 1rC%rCLaState Zip en
Office Phone: ( ) Cell -q Fax # E-mail t b J nowv�se
Ct ' Curie,
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
r I
Business Name/Type:,
Previous Business on this siteUl I
Describe the proposed business including use, number of employees, number of shifts, available arking sp ces, number of
vehicles, and any additional information that you can provide: '� S
O i �(
*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 tha ] own o the owner's permission to use the space indicated on this application. I also certify that the information provided
is true and a rate th e f m ledge. I have read the conditions of approval and 1 understand them, and that I will abide by them.
Signature Printed 1 AnAgn 3 Ct'j
APPROVAL INFORMATION
[ ] Approved as proposed [ ] Approved with conditions [ ] Denied
[ ] Backflow prevention device and/or current test data needed for this site. Contact ACSA, 977-451 1, xl 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 s 7 — Date
Zoning Officia Date
Other Official <'`�` CJt Date
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (434) 972-4126
C� Revised 11/1/2015 Page 2 of
7 sr C' ;�o I I
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1
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Intake to complete the following: I Reviewer to complete the following:
Y / N Square footage of Use:
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet. Y / N
Permitted as:
Y/N
Will there be food preparation? Under Section:
If so, give applicant a Health Department form.
Zoning review can not begin until we receive approval from Health Supplementary regulations section:
Dept. FAX DATE
Circle the one that applies
Parking formula:
Is parcel on private well or public water?
If private well, provide Health Department form.
Zoning review can not begin until we receive approval from Health
Required spaces:
Dept. FAX DATE
Y/N
Circle the one that applies
Items to be verified in the field:
Is parcel on septic or public sewer?
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Inspector : Date:
Y / N
Notes:
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the following:
Violations:
Y/N
If so, List:
Proffers:
Y/N
If so, List:
Variance:
Y/N
If so, List:
SP's:
Y/N
If so, List:
Clearances:
SDP's
Revised 1l/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, C1 lam- ra C I -" I — —q0
[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].
Si fiatfire of Applicant
y d Sn 01U/
Print Applicant Name
/-5 / a
Date