HomeMy WebLinkAboutCLE201200125 Legacy Document 2012-07-12Application for Zoning Clearance._,.,,._
Teti Oy AL /,,�,1G
CLE #_2W1- 12-5
PLEASE REVIEW ALL 3 SHEETS
OFFICE USE Y f_
Check # Date: to
Staff:
Receipt #
PARCEL INFORMATIOZ4 _ 6 2
(P
` l- Existing ZoningPa
Tax Map and Parcel: W�
reel Owner:—" 11mtyA t.J�� ftfa@��D
Parcel Address: �V� ��1 �G�• City L � 1 `� State Zip ZZ�
(include suite or floor)
PRIMARY CONTACT
V
Who should we call /write concerning this project? r'Q LEA ['L_
Address :500 esye J� 1 � i l �� l City �H A �ILTr"�Sid011�State ��—t Zip �f=1 I
Office Phone: C43A 9r%3- -,),3kj•7 Cell # Fax # E -mail )e_t3LA `3E ENIP�A, AAwi
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name /Type: U ey L. Q L-0 - %C S%'rQ -AN'
�u (Mownc)
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 i9 formation that y u can rovide:
GIN own '"1 2
J
*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 ertify that I ow h ne ' perm. on to use the space indicated on this application. I also certify that the information provided
is true a d ac cur e b dg 1 e read the conditions of approval, and I understand them, and that I will abide by them.
Signatur- --.... Printed
APPROVAL INFORMATION
"Approved 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 J-
Zoning Official Date
Other Official Date
County of Albemarle Department of community meveiopment
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
Revised 7/1/2011 Page 2 of 3
. e alK
Intake to complete the following:
Y /
Is us LI, III or PDIP zoning?
Engineer's Report (CER) packet.
If so, give applicant a Certified
Y /
Wil 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 publi ter?
If private well, provide He epartment form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that a plies
Is parcel on septic or ublic se
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 #
Zonin to com lete the following:
Reviewer to complete the following:
Square footage of Use:
-z, 25
6Y /N
Permitted as: e, mv'
Under Section: 2 2 .Z
Supplementary regulations section:
Parking formula:
J
Required spaces:
Y/
Items to be verified in the field:
Inspector : Date:
Notes:
Viol 'ons:
Y
If so, List:
Proffers:
Y I
If so" List:
Variance:
Y Sxist: �
If
SP's:
Y /
If so, tst:
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,
was provided to
[County application name and number]
[name(s) of the record owners of the parcel]
and Parcel Number
manner identified below:
the owner of record of Tax Map
by delivering a copy of the application in the
Hand delivering a copy of the application t t rt
[e record ecord owne r 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 to the following address:
Date
[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].
Si nature of Applicant
Print Applicant Name
Date