HomeMy WebLinkAboutCLE201700254 Application 2017-11-21-v
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Application for Zonin Clearance
CLE #
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OFFICE USE ONLY
PLEASE REVIEW ALL 3 SHEETS
Check # Date:
Receipt # Staff:
PARCEL INFORMATION !!
Tax Map and Parcel: d � � CiJ - z) - U-C— .; Existing Zoning I
Parcel Owner:
Parcel Address: ' S ((-f1 n//r-r- h %a ' � Cify� &te Zip
(include suite or floor)
PRIMARY CONTACT
�� �' ! ✓E1 `
Who should we caluwrite concerning this project? i''�
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Address: rL %'3c,"K s �; 4S City ( �� _ E i �i 4t; State L' f'— ZiFi= �
Office Phone: 3Fax # E-mail
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use off name(( New business
'Change
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Business Name/'Type: (/ �1 k 55ic5 �9yr�04041�s cello/� ('1 z " �c+�..nPt
Previous Business on this site
Describe the proposed business including use, number of employees, number of shifts, available parkin spaces, number of
vehicles, and any ddition I information that you can provide: a (o cc+ tuc�.; t� . a k,a 4 el 19-1,
�� �asfcs
camas U, nw �. 4 5 nitd n/•o o/
*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 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.
Printed S�?✓�cP� WnTk.-�
Signature
APYROVAL INFORMATION
Approved as proposed [ J Approved with conditions [ J Denied
[ ] B kflow prevention device and/or current test data needed for this site. Contact ACSA, 977-4511, xl 17.
[% to physical site inspection has been done for this clearance. Therefore, it is not a determination of compliance with the existing
site plan.
[ J This site complies with the site plan as of this date.
Notes:
/
Building Official i✓ Date
Zoning Official AAA Date
Other Official Date
Lounty of Aloemarie uepar2mcut v. aia..—v... ..-•-
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-M2 Fax: (434) 972-4126
Revised 11/02/2015 Page 2 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, Ze (\ t Ilq[ C `-Q,�X tq-yy t
[County application name and number]
was provided to T t P S �� E-(� �L( �� t i,q the owner of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number 4S 1y C-- by delivering a copy of the application in the
manner identified below:
ELIHand delivering a copy of the application to !- ` C-
[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 �l�ly�1"
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].
A,
Si ature of Applicant
sorlae'- 01 4 f -s
Print Applicant Name
I f/IS/%
Date
Intake to complete the following:
Y/N
Is use in LI, HI or PDIP zoning?
Engineer's Report (CER) packet.
If so, give applicant a Certified
Y/U
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 public water?.i
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 applies
Is parcel on septic or public sewer?
Y/N
Will you be putting up a new sign of any kind?
Sign permit. _
Permit# �NILG U, ViRE WA�6TE
If so, obtain proper
Reviewer to complete the following:
Square footage of Use:
Y N
ermittedas: 0GVlr
Under Section: Z,`; • 2 1 4 Z>
Supplementary regulations section:
Parking formula: 3 C, I - f 1 Z )
sect- MIGn . I�LS k+L Ie.0 f�YPGv
Required spaces: l
Yf N
Ite o be verified in the field:
P (11 i T I inspector:
Y /� tJvJB. U`,wiV�G �2417 QZIZ�
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the following:
Notes:
Date:
vw ns:
Y / N
s , ist:
Pr
YWSINf
Ift:
Var' ce:
Y (/ _
If sow, ist:
SP'
Y
If so, List:
Clearances:
SDP's p
to n
Revised 11/1/2015 Page 3 of
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