HomeMy WebLinkAboutCLE201900056 Approval - County 2019-05-22Application for Zoninlr Clearance
CLE # -
PLEASE REVIEW ALL 3 SHEETS
OFFICE USE Y
Check # oDate:
Receipt # Staff:
PARCEL INFORMATION _ 0 O-0 fo5 pp o w
Tax Map and Parcel: d S� �' Existing Zoning h C�" Z f'
ParcelOwner: C►'�-�"� t'«�
Parcel Address: 5-7Q . -rrtjo vdi1
W. City _ Cro 'Z-4°-V State Vft Zip
(include suite or floor)
PRIMARY CONTACT I
Who should we ca0/write this Wi 4 R M ':340 4�- l MD (�/��+NAM �!J•
concerning project?
Address: (9 o_ S a mo R.� � 1 City L) c,V2 A� I MZi �S ate Zap 2
Office Phone: ( 6 15'3`k Cell # 0L" V10' 71gq Fax It E-mail
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
q� M
4D Business Name/Type: 'li N 1'� QW'i J� � US Sj4CW &V L% rVre MT
Previous Business on this site SW" 7'7P5-�--
Describe the proposed business including use, number of employees, number of shifts, available parking spaces, number of
vehicles, and any additional information that you can provide: G P E�
*This Clearance will only be valid on the parcel for which it is approved. If you change, intensify or move the use to anew location, anew 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 21 /va D.fiL- Printed Z4� �V �k//I�i�S
APPROVAL INFORMATION
,yj 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
county of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (434) 9724126
Revised 11/02/2015 Page 2 of 3
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 /*I
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 one that applies
Is parcel on private well o ublic orate
If private well, provide Health Department form
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that a
Is parcel on septic public sewer?
YJ/ N
ill you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
/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:
Y/N
Permitted as: (SA (�
Under Section:
6 -
Supplementary regulations section:
n � c.
Parking formula:
Required spaces: ( f�
Y/N
Items to be verified in the field:
Inspector Date-
Notes:
Violations:
Y/N
If so, List:
P�
Y .
If so7sit":
riance:
Y/N
f so, List:
611 G - i -�.���
N
so List:
y- ��,,,1 �� lid)
Clearances:
SDP's
I Li lei
ni o
3.UC P —
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, 2;" 16 C lei
[County application name and number]
was provided to CM ZLf— C-644�� P" Q Y5 the owner of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number
manner identified below:
by delivering a copy of the application in the
Hand delivering a copy of the application to /)A( V6—�d
[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
QMailing 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].
A 1�7
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Signature of Applicant
Print Applicant Name /
Date
nt
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