HomeMy WebLinkAboutCLE201200165 Legacy Document 2012-08-07Application for Zoning Clearance
CLE it 0,4) 12 ` 5
PLEASE REVIEW ALL 3 SHEETS
OFFICE USE ONLY
Check # Cl I Date:
Receipt # Staff:
PARCEL INFORMATION Q�
251 Existing Zoning UA1 1 UX,
Tax Map and Parcel: w-
Parcel Owner: `2&44a,Y,l c��v�y�'D/I -
ff
�q Az V City I,o eSi/P�I� State �A Zips �
Parcel Address:
(include or floor)
PRIMARY CONTACT
Who should we call /write concerning this project. iT f7 Li t
9-24 La & City CWr esVj Jle State VA Zip
Address : S
Office Phone: 75 ,3533 Cell #43 0 ax # 3 -P'! . E -mail � P e I.B6 ej-)m
APPLICANT INFORMATION
Check any that apply: Change of ownership` Change of use Change of name New business
`
Business Name /Type: i_ , �si'I.fJ / Gtilrt�'�L tn�Lt'C'"T t�tl in
Previous Business on this site tLo, a W I
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: 3 mat r i 5�/TCpS
*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 the conditions of approval, and I understand them, and that I will abide by them.
k I rib
Signature Printed L,4
APPROVAL INFORMATION
'X] 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 T' t1—
Zoning Official e FeUa Date VJ12.61 �
Other Official Date
County of Albemarle vepartment of Lommun►ty meveiopment
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
Revised 7/1/2011 Page 2 of 3
El
Intake to complete the following:
Reviewer to complete the following:
Y / N Square footage of Use: 65L)
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.)/ N 11
ermitted as: r'jyM e- SC,�bu
Y/N Z
Will there be food preparation? Under Section:
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 SP Qy..
Circle the one that applies -
Is parcel on private well o lc Ovate .
If private well, provide He h De ent form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applie
Is parcel on septic or u lc se r?
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 #
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Parking formula:
Required spaces:
Y/
Item o be verified in the field:
Inspector:
Notes:
Date:
Violations:
(6/N
If so, List: /
Proffers:
Y/N
If so, ist:
Variance:
6Y /N
If so, List:
-- 33
R's:
/N
jj so, List;
f -;Z - 6►//����1
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 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
\1 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:
f> /
[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].
�ignatureofAppli nt
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Print Applicant Name
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Date
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