HomeMy WebLinkAboutCLE201200154 Legacy Document 2012-07-31Application for Zonin Clearance�`�'`
CLE # � � 1 � ' �
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OFFICE USE ONLY �7 �j
# g Date:
PLEASE REVIEW ALL 3 SHEETS
Check vl
Receipt # $ Staff:
PARCEL INFORMATION
Tax Map and Parcel: NOM Q- 0Q — 12' cot G2.1 Existing Zoning ��SG
Parcel Owner: E19 5 V130LUD 1AJ(
Parcel Address: SAOW wottfT Coutt cityCALA9 ALQ&SV�1� State VA. Zip
(include suite or floor)
PRIMARY CONTACT
Any
A m="i
Who should we call/write concerning this project?,,
015 �AI,IZ QX 4 . City M44+ -& State t J •G • Zil),WU7
Address:- 5 �Wr
Office Phone: ( , a/D Cell # Fax # E -mail fit' -A G/iWd4r
APPLICANT INFORMATION
Check any that apply: _Change of ownership of use Change of name New business
/CChangge
/ Lit
Business Namerfype: 6Tati MAC M ffilt k►i�
Previous Business on this site
Describe the proposed business including use, number of employees, number f shif , available parking spaces, number of
vehicles, and any additional information that you can provide: R&T�F! �°� t Ek+PLoYe�"S l 2 51>ilF%3'
"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-imowledge. I hwO read the conditions of approval, and I understand th64!!J emm,and I will abide by them.
!!that
Printed �iGErii�i r�'7N
Signature ..
APPROVAL INFORMATION
] Approved as proposed [ ] Approved with conditions [ ] Denied
[ ] Backflow prevention device and /or current test data needed for this site. Contact ACSA, 9774511, xl 17.
[ ] 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
Zoning Official Date ����/Za %7✓
Other Official Date
t;ounty of Albemarle tueparrmens or 1,ommumty Levewpweut
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
Revised 7/1/2011 Page 2 of 3
- : dpm
Intake to complete the following: Reviewer to complete the following:
Y I N Square footage of Use:
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet: - - t/ mitted 4A I J N as: c .
Will there be food preparation? Under Section: 2� .
If so, give applicant a Health Department form.
Zoning review can not begin until we receive approval from Health Supplementary regulations section:
Dept. FAX DATE
Circle the one that applies _ -
Is parcel on private well p�Department
Parking formula: - - - - -
If private well, provide Heat rm.
Zoning re view can not begin until we receive approval from Health
Required spaces:
Dept. FAX DATE
Y/
Circle the one that appli
Items o be verified in the field:
Is parcel on septic ublic sewer?
Y N
Will you be putting up a new sign of any kind? If so, obtain proper
Clearances:
Sign permit.
Inspector • Date:
Permit #
N
Notes:
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit # slbi zoo &57AG
Violations:
N
`f f so, List:
Proff
Y /
If so, ist:
Vans ce:
Y/
If so, ist:
SP's:
/ N
If so, List:
Clearances:
SDP's
Revised 7/112011 Page 3 of 3
1*
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 f6pG?_A1 'PEAL+Y Mir- 'tMeNT T U13- the owner of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number D(Dl DD 162, 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
_X__ Mailing a copy of the application to %W&% x -_4L +f mUG5.6W4 -"tz s*r
[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
[6VP 6ASs Ae f:., $ �l -7 �tlie t�T� X652,
[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].
of Applicant
6.a,0-(r D ae <PF;�
Print Applicant Name
c JdG� 1 /7. 20 /Ti
Date