HomeMy WebLinkAboutCLE201800092 Approval - County 2019-05-03APPROVED
by the Albemarle County
r.nmmitnity nPvPInnment Deoartmeni.
Application' for Zoning Clearance
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PLEASE REVIEW ALL 3 SHEETS
OFFICE USE ONLY
Check # (;z %L/L% Date: 114
Receipt # staff -
PARCEL
PARCEL INFORMATION _
Tax Map and Parcel: Existin€,, Zoning w \>��
Parcel Owner:
Parcel Address G� !+ ty State Zip``
(include suite or floor)
PRIMARY CONTACT
Who should we call/write
concerning this project?
Address:
"' City � State
l�
Office Phon)4Cell # (�
f% E-mail
APPLICANT INFORMATION
Ch
ec any that apply: Change of ownership Change of use Change of name New business
Business NamelType. ) 10"e' 41�_A'
Previous Business on this
Describe the proposed business including use, number of employees, am r of s available a s
vehicles, and any additionll information that yog can pgovide: g� - �1�1 I T rking paw, number of
*This Clearance will only be valid on a parcel for whi b it is a roved. 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
is true and curate a best of my I ve read the conditions of approval, and I understand them, and that I will abide by them.
Signatu Printed Y AfIE
C
APPROVAL INFORMATION
[XKApproved as proposed [ ] Approved with conditions ( ] Denied
[ ] Backflow prevention device and/or current test data needed for this site. Contact ACSA, 9774511, 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.
Building Official 17 Date
Zoning Official Date l
Other Official 42 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:
Y
Is use LI, HI or PDIP zoning?
Engineer's Report (CER) packet
If so, give applicant a Certified
Y / ITT
Will 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�rprmoviealth
Is parcel on public water?
If private we, Department form.
Zoning review can not begin until we receive approval from Health
Dept FAX DATE
Circle the�r pub
Is parcel septic r public sewer?
Reviewer to complete the following:
Square footage of Use:
Y/N
ermitted as:
Under Section:
Supplementary regulations section: (1'6 .
Parking formula: 3
Required spaces:
Y / N
Items to be verified in the field:
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit
Permit # Inspector
Y / N Notes:
Will there be any new construction or renovations?
If so, obtain the proper Permit
Permit #
Zoning to complete the following:
Date:
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
f >
Clearances: 11 '
SDP's
v
a, ,s 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) if the application is not the
owner.
I certify that notice of the application,
[County application name and number]
was provided to 4�9/m &A& the owner of record of Tax Map
[name(s) of the recor owners of the parcel]
and Parcel Number f by delivering a copy of the application in the
manner identified below:
Hand delivering a copy of the application to'2i/ rf
[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 offs for that entity]
on
te>
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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Si ture of Applicant
001 -c"Jis ��
Print Applicant Name
Date