HomeMy WebLinkAboutCLE201200185 Legacy Document 2012-08-31Applicati ®n f ®r Zoning Clearance
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OFFICE USE O Y
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PLEASE REVIEW ALL 3 SHEETS
Check # Date:
Receipt # ( Staff:
PARCEL INFORMATION ii ,, ``
Tax Map and Parcel: P`1 L1._D`� —1 Existing Zoning t ��u� ►�1
Parcel owner: BzIfl � (-i 4=
Parcel Address: 11-0 &r /( Ganef sr City U,!( state 1/41- 1� Zip
r-
(include suite or floor)
PRIMARY CONTACT
Who should we call /write concerning this project?
Address : '21 CIO & t � I &a r' C �> ` City �� ,v /r-State � Zip�a�
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Office Phone: &JC6 ,�Lq5-- 7L&ZCell #'/3L/-�c�d Yig�Fax #���%�9S- ��i4t7E- mail �a v�o/�co�uwc/t�t„ozi�,4", �
APPLICANT INFORMATION -
Check any that apply: Change of ownership Change of use Change of name New-business
Business Name /Type: L tr wt ('C
Previous Business on this site
Describe the proposed business including use, number of employees, number of shifts, av ilable parking spaces, number of
vehicles, and any additional information that you can provide: Cl( v
*This Clearance will only be valid on the parcel for which it is approved. If you change, intensify or move tl a usd to a new location, a adw 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 Printed
APPROVAL INFORMA N
�[,4Approved 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 JU Date
Zoning Official 22�nQ �'G Date
Other Official Date
County of Albemarle impartment of Uommumty Levelot,meuL
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
Revised 7/1/2011 Page 2 of 3
/1-01,
Intake to complete the following:
Is us0-in LI, i-II or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y /0
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 1�ubTi� v er?
If private well, provide Healt .De pctifient 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 Lptflbff—cs`ewel .
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 #
Reviewer to complete the following:
Square footage of Use: O-D
(2) / N ,
Permitted as: e- Se
Under Section: o 7 )
Supplementary regulations section:
Parking formula:
Required spaces:
Y/N
Items to be verified in the field:
Inspector : Date:
Notes:
Violations:
YIN
If s � j'st:
Proffers:
Y /7N
If sciy I1st:
Variance:
If so, st:
SP's:
If so, ► t:
Clearances:
SDP's
Revised 7/1/2011 Page 3 .of3
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 ]En 10 u-0-
[Name of the record o er 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 Slagllt
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].
Signatu4re-ic�a�n FCLP It
Print Applic nt Name
FLpolo
Date