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HomeMy WebLinkAboutCLE201200129 Legacy Document 2012-07-12Application for Zoning Clearance `�:•� 2612-12-9 l;,"'`�� CLE# aN � /17pIN \Pi PLEASE REVIEW ALL 3 SHEETS OFFICE UU O Y Check # ��'J Date: 1, "1 2 -12- Receipt # Z Staff: PARCEL INFORMATION Tax Map and Parcel: S 4 A Z —I — Z9 Existing Zoning 4 LD Parcel Owner: (. cm - 7 --e-- _ �i p ��i F� 7°1 /le ►- � Parcel Address: 1'7. 3© re2 i0, � City State Zip2�J' (include suite or floor) PRIMARY CONTACT r Who /write Ac6m Gi GkII lL°y should we call concerning this project? p Address : 51-30 I ky-Ce_ t4n�e_ke � City t� 0.2_ t State Zip ZZZ Office Phone: (q ) $ 23_ j tf Cell # y3gQ'921� Fax # � ��3 - i$w E -mail e i l a�,a • ��-r, APPLICANT INFORMATION Check any that apply: Change of ownership Change of use Change of name New business Business Name /Type: Previous Business on this site Describe the proposed business including use, number of employees, of shifts, available parking spaces, number of rnumber vehicl`es,IIaAnd an 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 accurate torthe best of my kno sedge. I have read the conditions of approval, and I understand them, and that I will abide by them. Signature. PrintedG► %�! APPROVAL INFORMATION– Approve d 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 c, by 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 7/1/2011 Page 2 of 3 7 Intake to complete the following: Y/N Is us in LI, HI or PDIP zoning? Engineer's Report (CER) packet. If so, give applicant a Certified 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 or lic wat r? If private well, provide Heal De •t ent 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 rib le sew — . Y/N Will you be putting up a new sign of any kind? If so, obtain proper Sign permit. Permit # Y/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 Square footage of Use: -2-1 & N Permitted as:L Under Section: �L Supplementary regulations section: Parking formula: � Required spaces: Y/a Items to be verified in the field: Inspector: Notes: Date: 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 7/1/2011 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 64-b 2e,� -5/V QQe'r7 , 642, the owner of record of Tax Map [name(s) of the reco d owner of the parcel] and Parcel Number / � r — /— A7 by delivering a copy of the application in the manner identified below: �✓ Hand delivering a copy of the application to f!`ro2GT fl;t) j �- & [Name of the record owner wner 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 611L,701 Z 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]. ature o Applican ALtt-a r,gr -, Print Applicant Name 1// a4/.)- Date I