HomeMy WebLinkAboutCLE201200179 Legacy Document 2012-08-313 --
----- - - - - -- _Application for -honing- Clear -ante - -- -- - - - - -- -r
�� --
PLEASE REVIEW ALL 3 SHEETS
OFFICE USE ONLY
Check# 16 3%J Date:
_
Receipt # 5 l ID Staff:
PARCEL INFORMATION
Tax Map and Parcel: �el: (M �[ z,� j Existing Zoning
+,�
Parcel Owner: M-(G iae ( 6
Parcel Address: I I q?� ckou+ At City State M Zip o7cZ%
(include suite or floor)
PRIMARY CONTACT
Who should we call /write concerning this project? GA- ass c W l S
Address : (03Q R)u G�ld b✓d t City
State VA Zip 3Z
Office Phone: (Y& I %M-W80 Cell # 31��I—(lf �J 80 Fax # E -mail �Q Inl� LLI S ADS ° Glul4l(.
APPLICANT INFORMATION
Check any that apply: Change offoownership Change of use Change of name New business
/''�
Business Name /Type: _ ( xoz,E -�" ` cYh.ki De —[t-k l �G'Vl`fZC�I
Previous Business on this site gmeyc4 f" 74y low
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 pr vide: { cc � �n
,fj 2 aceo >n rn.�
*This Clearance will only be valid on a 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. have read the conditions of approval, and I understand them, and that I will abide by them.
/I
Signature iC/` Printed JGfi /JL�S U/✓ , �'�� ��/ f
APPROVAL INFORMATION --
] 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
Zoning Official Date
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
Intake to _complete the following: ___ __ _ _ _ _ _ _ __ _ _ __ _ _
_ Reviewer to complete the following_
Y / N
f
Square footage of Use:
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
e / N
Permitted as: I c,�' C>
Y/N
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
Circle the one that applies
Is parcel on private wey' or pub-11c wa er?
If private well, provide H th De ent form.
Parking formula:
/J J
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Required spaces:
Y/
Circle the one that applies_ ---�
Items to be verified in the field:
Is parcel on septic r public sewer?
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Inspector : Date:
Y / N
Notes:
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to com lete the followin :
Violations:
If o; fist:
Proffers:
Y /Fl
If so" fist:
Variance:
If o; List:
SP's-
Y /?
If so, List:
Clearances:
SDP's
Revised 7 /1/2011 Page 3 of 3
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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, an I n G C Itog o vi 6e
I V [ unty application name and number]
was provided to M iae l -6 (` n pwinCie ✓ the owner of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number 05106 2010 oo ZO A 0 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 M t chae L`Z 141-e y4hd&P-
[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 �I f `�'� Z to the following address:
Date
_7051 LOPU 0horloWesy6llt 04 o?aaoi -rff7
[address; wiitte(i 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].
re of Applicant
jamej IV A// d ij
Print Applicant Name
Y/-15 ! 19-
Date