HomeMy WebLinkAboutCLE201200156 Legacy Document 2012-08-07Application for Zoning Clearance�tr:.�
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OFFICE USE O
PLEASE REVIEW ALL 3 SHEETS
Check # Date:
Receipt # Staff:
PARCEL INFORMATION
��5�I % ' � � D 6 J0 0 1,o/� � Existing Zoning L�
Tax Map and Parcel:
Parcel Owner: �� �9(�
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Parcel Address:7-,�?-16 St mifiak-_ L Qy?e— ity C _Y\ ( r State VC, Zip Z U
(include suite or floor)
PRIMARY CONTACT�,�Y\
Who should we call/write concerning this projects
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` Zip
Address : 155 K-! -\ �� C, City li State V J
Office PhoneiP ) ?J`7 Cell # -I001 _ Fax # E -mail
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
__3Business Name /Type:����
Previous Business on this site
Describe the proposed business including use, number of employees, number of shifts, vailab par n s aces, number of
��
icles and any additional information that ou an 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 tnbe if my k nowledge. I have read the cond' ' of appr , and I understand them, and that I will abide by them.
���✓� t�'�I'1C
Signature mted� \ lGt
APPRO§'as I RMATION
Approv proposed Approved with conditign [ ]Denied
�tes<tdata
[ ] Backflow prevention device and /or curren needed for this site. Contact ACS A, 977 -4511, x117.
No physical site inspection has been done for this clearance. Therefore, it is not adeter)mination of compliance with the existing
site plan. �� i)i d.5/ Z., A.57 I4y ti - 5_7Md �
[ ] This site complies with the site plan as of this date. �"
1 P
Notes: /yl 7'Tn 1� '�� CI l
Building Official Date
Zoning Official Date /20/
Other Official Date
County of Albemarle Impartment or k,ommumty Leveiut,n►euL
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
Revised 7/1/2011 Page 2 of 3
n
Intake to complete the following:
Y/N
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y N
W t re 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 blic wPnt
If private well, provide Hea De a rm.
Zo ning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that appli
Is parcel on septic or lic sewer?
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Per #
/N
ill re be any new construction or renovations?
If , obtain the proper Permit.
Permit #
7nninu to complete the following_:
Reviewer to complete the following:
Square footage of Use:
6' / N /
Permitted as: c 15 i4 Z 3�+� j�V its
Under Section: 2Li>
Supplementary regulations section:
Parking formula: / of
�>
Required spaces:
Y/N
Items to be verified in the field:
Inspector : Date:
Notes:
Violations:
/ N
f so, List:
A bA4
Proffers:
Y /
If so, List:
Vari;, nce: SP's:
Y/I
If so, List:
iD /N
If so, List:
Clearances:
SDP's
Q � 1dj
Revised 7/1/2011 Page 3 of 3
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6
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, 6LL 2617 --154
[County application name and number]
was provided to
[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 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 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].
Print Applicant Name
Date
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