HomeMy WebLinkAboutCLE201900177 Application 2019-08-06Application for Clearance
�/Zoning//
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isCLE#
PLEASE REVIEW ALL 3 SHEETS
OFFICE USh ONLY
Check # -Z Date:
Receipt # Staff:
PARCEL INFORMATION � � , 3 � D -RA
Map
and Parcel: Existing Zoning
Parcel Owner:_ COQ 1J STU 1J G- COM M lJ 1Ty to k-}ul CF-y
+V,
Parcel Address:_ ZOO I C-O.�(ySJ � `�� City GnA c1 oEfPS�� � IeState VA Zip 7�Z93
(include suite or floor)
PRIMARY CONTACT
Who
should we call/write concerning this project?
Address • y 00 L.Oc..lC�-+ k�P . G3 City "I le- State V � ZipZ2�0�
Office Phone: t '- 'I 917-Le�-A�ell # oA{)-<G(PCFax # N A E-mail d� DMt'�^o�ty► S
APPLICANT INFORMATION
Check any that apply: Change of ownership A/ Change of use Change of name New business
Business Name/Type: �.1M I DY1 '�)re-Lz t rwl Faf rem + 4ca r-pon')
Previous Business on this site Ch I t ViC_k
Describe the proposed business including use, number of employees, number of shifts, available parking spaces, number of
vehicles, and any additio 1 information that you can provide: t' CZ° 1.JQ t' -ku-_' � S'CC7
)_1 or � e;,+S • -*' 1
'
uc1� S vn Oq Ce- rn (c e
n I r ►� c�S ,r S o A i r1 • i"
*This Clearance will onlylbe valid od the parcel fopAwhich it is approved. If you change, intensify o ove the use to a n& to tion, neing
Clearance will be required. ��Q ref
1 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 t of�M�nowle read the conditions of approval, and I understand them, and that11 will abide by them.
Signatur Printed'
APPROVAL INFORMATION
f ] Approved as proposed f ] Approved with conditions f ] Denied
[ ] Backfilow prevention device and/or current test data needed for finis site. Contact ACSA, 9774511, 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
Other Official Date
%.ounry of AiDemarie 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 /6�
Is use in LI, HI or PDIP zoning?
Engineer's Report (CER) packet.
If so, give applicant a Certified
'YJ/ N
dill 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 ' yuve- yy�
Circle the one applies
Is parcel on ri a e well or public water?
P
If private wel , provide Health Department form.
Zoning review can not begin until we receive approval from Heahh
Dept. FAX DATE
Circle the on at applies
Is parcel onror public sewer?
Y
Wi u be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y
Wil )ere 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:
Under Section:
Supplementary regulations section:
Parking formula:
Regained spaces:
Y/N
Items to be verified in the field:
Inspector: Date:
Notes:
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 I I/l/2o15 Page 3 of
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, LC
[County application name and number]
was provided to CDC Qe4--*9ne- CpMYKLLV% V [A -the owner of record of Tax Map
[name(s) of the record owners of the par el]
and Parcel Number L�s " 3,D by delivering a copy of the application in the
manner identified below: ff�
Hand delivering a copy of the application to�otiU 1—t'rCX# :��e--
[Name of the record owner if the record owner is a C*1"un.
person; if the owner of record is an entity, identify the recipient of the record and the recipient's Chu Y'C IA .
title or office for that entity]
on D Z0' q
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].
oaturepplicant
Print Applicant Name
Date