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HomeMy WebLinkAboutCLE201200160 Legacy Document 2012-08-07Application for Zoning Clearance CLE # (o© n OFFICE U W 9 12— PLEASE REVIEW ALL 3 SHEETS Owe # Date: Receipt # Staff: PARCEL INFORMATION Tax Map and Parcel: 0- Existing Zoning Owner: i a,r �• �> I � v V4 1 &0 Parcel l b Parcel Address: Zi Z ' l 1 2 (include suite or floor) PRIMARY CONTACT Who should we call /write concerning this project? Address: City State Zip a Office Phone: Cell # y3, ��!Sr1 Fax # E -mail ,0911 &V.S•%.Z'u.c�,iNQ APPLICANT INFORMATION Check any that apply: Change of ownership Change of use Change of name New business Business Name /Type: 41.4 L j 5A V e- _Q Previous Business on this site 71- X`e— 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: *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 tl conditions of approval, and I understand them, and that I will abide by them. Signature Printed 4 e--f 4 , XC APPROVAL INFORMATION [N °J Approved as proposed [ J 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 t —_ Date Z a I l Zoning Official Date ,?11zz61 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 Cas*1t- .0 G'Ct/­2_ 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 /PN Will there 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 public 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 applies Is parcel on septic or public sewer? Y / Wil ou be putting up a new sign of any kind? If so, obtain proper Sign permit. Permit # Y / Wil ere 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: > U Y) /N L Permitted as: AZOAJ 6' � zM;' A Under Section: Supplementary regulations section: Parking formula: Required spaces: Y/N Items to be verified in the field: Inspector: Notes: Date: Violations: Y/ P, If so, ist: Proffers: Y/ If so, ist: Variance: ( If so,Zist: SP's: Y /N If so,Zist. Clearances: SDP's Revised 7/1/2011 Page 3 of 3 u1se, IN 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 the owner of record of Tax Map [name(s) of the record owners of the parcel] and Parcel Number 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 [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]. Signature of Applicant Print Applicant Name Date