HomeMy WebLinkAboutCLE201700238 Application Zoning Clearance 2017-10-27Application for Zoning Clearance
CLE# 26 /•26-4 E-12-2
PLEASE REVIEW ALL 3 SHEETS
OFFICE USE ONLY
Check# C% Date: 7d
Receipt # Staff:
PARCEL INFORMA sIQ1 ��j.�✓s y� Dl9 / �901 C�Gs—G
Tax Map and Parcel:��'������ Existing Zoning
''ry'
Parcel Owner:
Parcel Addres���/02 G�/r/yt City
(include suite or floor)
PRIMARY CONTACT
Who
should we call/write concerning this project?��ti
Address ��a/.� ��1��r� City( ./ IJY,11/State
Office Phone:�j �9 Cell # �� �� Fax #���'�G E-mail fn
APPLICANT INFORMAYXON
Check any that apply: Change of ownership Change ofuseChange of name New business
Business Name/Type: �� �-U �� ��/Gi,�/ jam ,�J�-S 3 ��JG'l��r� ��' .S-
Previous Business on this siter/!//�ft/`�'.y�
Describe the proposed business including use, number of employees, number of shifts, available parkin paces, num er of
vehicles, and any additional information that you can provide:
*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 accura of my kno ledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature Printe s��J✓�� /�.�/
APP OVAL INFORMATION
N,of.Approved as proposed [ ] Approved with conditions [ ] Denied
[ ]Bar ow prevention device and/or current test data needed for this site. Contact ACSA, 977-4511, x117.
o 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
114� � 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) 972-4126
Revised 11/02/2015 Page 2 of 3
Intake to complete the following:
Y /(1V
Is useinLI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y
Will ere 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 ublic water?
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 o public sewer.
Y / 1V
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit # /�®/ 1�dlii✓
Y/N
Will there be any new construction or renovations?
If so, obtain the roper Permit.
Permit #
Zoning to complete the following:
Reviewer to complete the following:
Square footage of Use: t� Z
Pernn
N
itted as: G I OTgs ►dr\ ail
Under Section: 2Z -L' 1 % C l
Supplementary regulations section:
Parking formula: L
n
Required spaces:
Y j N
Items o be verified in the field:
Inspector : Date:
Notes:
Vio i s:
Y kN
If so, ist:
Pro s:
Y
Ifs ist:
Va ' ce:
Y
If so, ist:
SP's:
Y/N
If so, List:
19°I� —Z3
lot 9�—Ir
Clearances:
SDP's
Revised 11/l/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� the owner of record of Tax Map
[n�` ame(s) of the record owners of the parcel] zze
and Parcel Number by delivering a copy of the application in the
manner identified below:
Hand delivering 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
® 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].
ignature of Ap licant
Print Applicant Name
Date
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