HomeMy WebLinkAboutCLE201700223 Application 2017-11-16 (3)Application for ZoninT Clearance_®fig
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i�RGIN�P
PLEASE REVIEW ALL 3 SHEETS
OFFICE USE ONLY
Check # Date:
Receipt # Staff:
PARCEL INFORMATION
L I
Tax Map and Parcel: 11 ��� —� Q� (� Ko Existing Zoning
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Parcel Owner:
Parcel Address: ng0l�.'lX'I&�i ST. Sif_ i I City CJN0A' State V i14r— Zip '
(include su' or floor)
PRIMARY CONTACT (�
i_.�%OP&_ A �,,,,
Who should we call/writ(e� concerning this project? Dr:Sj
Address : 9l3 State UA ZiR,23a�
Office Phone: $( l7j) 4-11—S� 2 Cell #�SQ 4 t@+ax # E-mail �QUrt� �L�,i�,'� Q���{�,ICS� A
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use\ Change of name New business
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Business Name/Type: CiD012�C)i;\+gQni Yt.SLLC_
Previous Business on this site
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: D i5 OU + JC4-..S
C tJstmgc-_,� �,j n ppi. on
*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.
Signatu e Printed {- L N
APPROVAL INFORMATION
[Q.,Kpproved as proposed [ ] Approved with conditions [ ] Denied
[ ] Backflow prevention device and/or current test data needed for this site. Contact ACSA, 977-4511, x117.
[ LIXo 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 C Date
Zoning Official Date ! llit
Other Official Date
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (434) 972-4126
)1-7
Revised 11/02/2015 Page 2 of 3
Intake to complete the following:
Y
use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y
Wi e 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 or blic 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 appli
Is parcel on septic o ublic sewer.
/N
u be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y/N
W e 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: 2,10 W—
Y I N
ermitted as: St0 Yg AP- t P 60J
Under Section:
Supplementary regulations section:
Parking formula:
I Oloyef (l,s}omcr
Required spaces: 2—
Y(/ N )
Items —moo be verified in the field:
Inspector : Date:
Notes:
Vio�ons:
If so -Fist:
Pr
t:
If 'so —,List:
V e:
Y /
If � ist:
(YDN
so, List:
toig— 13 gyoadv l So(cer
-La1-7 - ly CV1IIe -Sir, Iins t"ife,
Clearances:
SDP'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,
[Coudty application name and number]
was provided to V 'To C— the owner of record of Tax Map
[name(s) o the rec rd owners of the parcel]
and Parcel Number 01100'CD•-CW4 Q KL 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 (Ywga(� NS�N
[Name o4 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 Q6_ �aDF1 to the following address:
Date
Fr-.e. 0�1C n . ` A C9149q_0
[address; written notice mailed to the owner at the Iasi 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].
Nut 1"
Si Uum
re of Applicant
Print Applicant Name
IT)- 3-1
Date
Lease Agreement - VAS of \rrginia-genericl70322.docx 22 Of 24 vl 70227