HomeMy WebLinkAboutCLE201200177 Legacy Document 2012-08-249
Application• for Zoning Clearance s°V AI .
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Ol?R`10E US NLY
PLEASE REVIEW ALL 3 SHEETS check # l Z� Date: Lo- I Z
IMILO
Receipt # 0 Staff:
PARCEL INFORMA.TION
Tax Map and Parcel: Existing Zoning_
Parcel Owner: JiS'R1M.
fi. .. ..•:
Parcel Address( T 1. tb mss.. _. City -is State �:ai Zip
t, _, •. i clod ite or- floor} _ ,
PRIMARY CONTACT
Who sbould we call/write concerning this project?
Address :� S�" Clty'._State.
fax #
3 Office Phone:,( E -inaii wy .
�� 1�-lell #
APPLICANT zrr o.RMA zON...
Check tiny that apply:• Change of ownership . Change of use Change; of name; 1e;Y Business
Business Namefl`ype
1�Previous Business on this site - •
Describe the proposed busbiess including use.-number-of eraployc�, nnmbe f shy , a� ailz;b�eparktng spaces, number of .-
yni._.
*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 locati0N,atew Zoning
Clearance will be requ' „
L hereby Ge ' that I oiim o h .e tlfe owae's pemusmon -to use "the space iddicated'on this application. 1 also certify that the infbr nation provided ;
is true grid ciliate to.ifie of my knowledge. I.have read.the condiflons ofapproval, and 1 understand,them, and,that I -U-- bide lry them.
Signature.:.,
}
APPROVAL INFORMATION
1¢,<J Approved as proposed [ ] Approved with conditions
[ ] Backflo%wprevention device and/or current test data needed for this site. Contact t1CSA, 977 4511; a 117
[ ] No physical. site inspection has been done for this clearance Therefore, it is not a determination of carapirance with the existing
site plan:...
( ] This site complies with the site plan as of this date.
Notes: _ ....._
Building Official Date � � ` Z�.
/ }
Zoning Official Date���!�1
OtherOfficiai .. _ Date .
Caunty of Albemarle l)eparfinentof Community Development
__..- 401 McIntire Road Cbarlottesv ie' VA 2,2902 Voite: (434),296- 5832 Fax. {434} 9't2.41 -26• -• -
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Revised 7 /1/2011 Page;2 of 3
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CERTIFICATION THAT NOTICE OF THE
'APPLICATION HAS SEEN:PROVIDED TO THE LANDOWNER
This form must accompaity zoning app#catwns (Home Occupation, Zoning Clearance, Zoning
Administrator Determinations orAppeais, Sign Permits, Buiiding Permits) if the,applicativn is not the
owner.
T 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 cagy 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..tiie:record.and. the rocipient'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 amity]
on • t ! •�Z" 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]. > �
Signature of Applicant
:Ti
.Print Applicant Name
Date
n .,
Intake to complete the following:
Reviewer to complete the following:
Y AS>
Square footage of Use; --7-3y3
Is use in LI, HI or PDIP zoning? if so, give applicant a Certified
Engineer's Report (CER) packet]
Y1 �
Will there be food preparation?
N
Permitted-as:
Under Section: 2 S
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
SPIS•
Y/
If A -elst:
Circle the one that applies
Is parcel on private well or blic.water?
P'ar'king formula,.
If private well, provide Heal ent form.
Zoning review can not begin until we receive approval from Health
Required spaces:
Dept. FAX DATE
Clearances:
•Y /N
Circle the one that applies
is parcel on septic or tic sewer?
Items to be verified in the field:
N
Wil I you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Inspector : Date
Q/1 N
Notes:
l there be any new construction or renovations?
If so, obtain the proper Pdernut.
Permit #
Violatons:.
If so, List:
Proffers:
//K
If so;`List:
Variance:
I so,i ist:
SPIS•
Y/
If A -elst:
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3