HomeMy WebLinkAboutCLE201200167 Application- - - -- A -ppl cat ® f6r -Z -ring clearance
-� 9
OFFICE USE ONLY
PLEASE REVIEW ALL 3 SHEETS
Check # Date:
3
Receipt # Staff:
PARCEL INFORMATIO - -- - - - - - - - - - - -- - -- -- --- - - - - --
6 Z. -1-2q
Tax Map and Parcel: Existing Zoning L15
Parcel Owner: 0 vx, Q— S y t O c� � 2 S � L L- G
Parcel Address: 5'194 Th �r •e_ e. o� ro City GV 2 State V �- Zip 7-Z73 `
(include suite or floor)
PRIMARY CONTACT
Gi t Gj Ll 0 V GLkl
Who should we call /write concerning this project?
Address: Z 12 S V � j P_ A, 5V; i-2_ � City ('�%a J Zg0
,State
Office Phone: () Cell # .fig _0 2G$Fax # YS S-0334 E -mail
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
c
Business Name /Type: C�V P 0.�'vL 2. ��Av-A i ^ �l Tv\ S0 X
Previous Business on this site —0 I ',j 'e— TC .e..e--
Describe the proposed business including use, number of employees, number of shifts, available parking spaces, number
vehicles, and any additional information that you can provide: t ; ci,,/ 4-- _S Ln'n lj4 Saw a�c�
��C �{ aD ✓ (2 i S.6 � -Q o�v�- --
*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.
Signature l LiZ Z �s eC �Il Printed _/J,,20 &:� A �6
APPROVAL INFORMATION
Approved as proposed [ ] Approved with conditions [ ] Denied
[ ] Bacictl.ow 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
Zoning Official 4A Date 'q/740/ Z,
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
A
Intake to complete the following:
Reviewer to complete the following:
Y/ N
Square footage of Use: 1 n B
Is use in LI, .HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
/ N
I
-Will there be food preparation.
Permitted as: /eti
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
Circle the one that applies
li
Is parcel on private well or c water?
Parking formula:
i� oo N
If private well, provide Health Department form.
Zoning review can not begin until we receive approval fi•om .Health
Dept. FAX DATE
Required spaces:��
SDP's•__
Circle the one that applies
Is parcel on septic or _lic sewer
Items to be verified in tiie feid:
I / N
ll you be putting up a new sign of any kind? If so, obtain proper
Sib i permit.
Permit #
Inspector : Date:
Y /
Wi1I tth'ere be any new construction or renovations?
Notes:
If so, obtain the proper Permit.
Permit #
ZoninLy to complete the following:
Violafi ons:
Y/I
If so, List:
Proff s:
Y/ �
If so -,List:
Varia ce:
Y/N
If so, . ist:
P's:
/N
I.f so, List:
Clearances: / % q
SDP's•__
Revised 7/1/2611 Page 3 of 3
CERTIFICATION THAT NOTICE OF THE
APPLICATION HAS BEEN PROVIDED TO THE LANDOWNER
This form must accompany zoning applications (Horne 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:
`� Hand delivering a copy of the application to
the owner of record of Tax Map
by delivering a copy of the application in the
[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
41�41 All
Print Applicant Name
'— 2— /2-
Date
1.5716 "
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