HomeMy WebLinkAboutCLE201200211 Legacy Document 2012-10-08Application for Zoning Clearance
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OFFICE UST+ ONLY
PLEASE REVIEW ALL 3 SHEETS
Check # Date:
Staff:
Receipt #
PARCEL INFORMATION
Tax Map and Parcel 0-79)60 00-00 017140 Existing Zoning
Parcel Owner: ggy-Icn/ S'rY►xJW
Parcel Address: cy,,+E• 6 City State 'VA, Zip 2.Z`31 1
(include suite or floor)
PRIMARY CONTACT
Who should we call /write concerning this project? Xf- s-lrh1 SYYI.Z•-Nj
Address : P o • 6a X 8003 City C6d-lt tokff 5Uc'f /E State VA Zip 22906
Office Phone: CY3 Jj 243�8'165f Cell #Y3(F Z%;- OZ6(.Fax #q�Yq7/ �i226 E -mall %�LSn1 t12lgQ�rAFfoo. Cowl
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name /Type: 5EC Lx /Z&1 S O 'LL41 i Q iN S Cs Qy u•j� :ZN C-
Previous Business on this site
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 provide: E LsSnj &-s o 'i ei✓'� . T �o A2 +�tnsE
*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 Printed s "s"A
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 1,3� ( e
Zoning Official Date -IAI3 -7-0)
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:
Y /0
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y /b
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 o par�tinent r?
If private well, provide H form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that app '
Is parcel on septic o is sewe
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 #
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Reviewer to complete the following:
Square footage of Use: b 7y
0 / N
ermitted as: �,� ; Ni4 d� c°J
Under Section: 2.5- ,2 - I
Supplementary regulations section:
Parking formula:
Required spaces: .
Y /%
Items o be verified in the field:
Inspector : Date:
Notes:
U V 11111
Violations:
Y/
If so, ►st:
Proffers:
�/N
If so, List:
VarO"i e:
SP's•
YIt Not: If so, List:
Clearances:
SDP's
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Revised 7/1/2011 Page 3 of 3
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,
[County application name and number]
was provided to IZ6y / <ePtFi7w the owner of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number
manner identified below;
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
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Print Applicant Name
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Date
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