HomeMy WebLinkAboutCLE201200195 Legacy Document 2012-09-28h as +
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Application for Zoning Clearance:
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CLE # Gd I Z- 1q5
OFFICE IJ ON Y
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PLEASE REVIEW ALL 3 SHEETS
Checic# Date:
Receipt # ,95— Staff: /
PARCEL INFORMATION �� _
Parcel: ��JJ r-' 0 � �
Tax Ma -�xistin Zonin
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Parcel Owner:
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Parcel Address: 116, o )1 Pkc ' r S L 3 � City( )U lte_.. State V4- T ZipW 90/
(include suite or floor)
PRIMARY CONTACT
Who should we call /write concerning this project? L6 Ut 4 111.✓ '"
11� �3 �tJes) %)City �iL�r+,,c4 /III Zi�!I
Address: State
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Office Phone: c �� y ()Cell # Fax # 3�y cl3> -y(� /�Z E- mail �VQ QW&1rC0C�YylGrj
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name /Type: Aql mil't < F::I:q Lq Q L_
Previous Business on this site V\V\
Describe the proposed business including use, number of employl8es, nu.m er of shifts, availabldparlcing spa esi umber of
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vehicles, and any additional inform tio0 that you can provid a<: 2
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*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 certi or have the owner's permission to use the space indicated on this application. I also certify that the infonnation provided
is hue and a curate to the st of my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature Printed AY� �--t•
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 `Z (it (('a—
Zoning Official Datelj
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 7/1/201 1 Page 2 of
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Intake to complete the following:
Y/N
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y�
Wil] 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 o blic titer?
If private well, provide He
ti Depar ent form.
Zoning review can not begin unti we receive approval from Health
Dept. FAX DATE
Circle the one that applies
Is parcel on septic or p lic sewer?
Y/N
Will you be putting up a new sign of any kind?
Sign permit.
Permit #
If so, obtain proper
Y/N
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zonina to com lete the followin :
Reviewer to complete the following:
Square footage of Use: f () 0 7
(Y)/N
Permitted as: h/4,i&& S aoC 4e,
Under Section: '2'-•12
Supplementary regulations section:
Parking formula: �J
Required spaces:
Y/N
Items to be verified in the field:
Inspector : Date:
Notes:
Violations:
Y/
If so, t:
Proffers:
Y/
Ifs ist:
Variance:
Y/0
If so, List:
SP's:
Y /I
If so, List:
Clearances:
SDP's
Revised 7/1/2011 Page of
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
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
Print Applicant Name
Date