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HomeMy WebLinkAboutCLE201200217 Legacy Document 2012-10-12Application i ®r Z®ni n Clearance j OFFICE U SE Ip - i I Z PLEASE REVIEW ALL 3 SHEETS 4 Date: # Staff: —TT_ Receipt ,71 PARCEL INFORMATION �� r Tax Map and Paarrcel; y I •/ 1 - ��%1\ ®� Existing Zoning 1 Parcel Owner: I\��6Inc'�2��{' �`thCA`F �irS`�l(►C �L� �Q��NlVtes Q1�V Parcel Address :3SC0 &,MS61) City 0.)�G1 R�6Ae-,s0'%W State y Zip (include suite or floor) PRIMARY CONTACT 1 'J �� �t Who should we call /write concerning this project? IVY 1VA 16 GGw �E,�'►►ScJYI a City ��4�IO�PS1%I I19- State Zipaag° o0 Address:'- Office Phone: I L X71 3U-q96 2 Cell # Fax # E -mail M (, qt-V�t-01-j ka,9 -r oR APPLICANT INFORMATION Check any that apply: Change of ownership Change of use Chphange of name New business Business Name /Type: �tiQ Qt 1z.1i1 1• V1 e� �\ \ k' ^ )DR,Oi 0.L2�1i U t !0 i�i� a SA 4 Previous Business on this sit Re- o-n-PzA I ►)l �� `7�� 1� 1� �1_�I`e 1 eG Describe the proposed business including use, number of employees, number- of shifts, vailable parking s _ ces, number of vehicles, and any additional information that you can provide: Co h-� l lAcaka n n� Ylo� - p� 6�i� *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. 1 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 to the best of my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them. �ocurate Signature Ja.1kAX Printed I �a a \ Yl Cjn5� QA A 1 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 10 Date Zoning Official 4C 4 Other Official Date County of Albemarle ilepar[ment of t.ommunny llevelulJ111c111 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/N Is use in L1, HI or PDIP zoning? If so, give applicant a Certified Engineer's Report (CER) packet. Y /�tiere Wil 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 public water? If private well, provide Health Department form. Zoning review can not begin until we receive approval from Health Dept. FAX DATE Circle the one that app 'es Is parcel on septic o public sewer? J/ N Will you be putting up a new sign of any kind? If so, obtain proper Sign permit. Permit # Y /@ Will there be any new construction or renovations? If so, obtain the proper Permit. Permit # 7-- 4-^ -"1a +a +h'M fA11AW1n Q• Reviewer to complete the following: Square footage of Use: //., 9 9 /N ermitted as:� -e- Under Section: 22. -11 ' I Supplementary regulations section: Parking formula: Required spaces: 33 . yJ c-l- Y/N Item to e verified in the field: Inspector : Date: Notes: VV1111L 1.V VVlla J1V �V 4a1V 1 Violations: Y / If so, st: Proffers: Y/ If so, ist: Variance: Y If s SP's: Y/N If so, List: Clearances: SDP's c� 5 —zy Q� y �69 Revised. 7/1/2011 Page 3 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]. L tin i v) Q� �) �m 1 �. Signature of Appplicant Print Applicant Name �2- Date