HomeMy WebLinkAboutCLE201200190 Legacy Document 2012-10-12Application for Zoning Clearance`
CLE #
OFFICE U LY
PLEASE REVIEW ALL 3 SHEETS
Check# Date: .'
Receipt # Staff:
PARCEL INFORMATION -
Tax Map and Parcel: Existing Zoning_
Parcel Owner: t �'lC V —,
Parcel Address: City (�it� d' I Df'k State Zip U1.0
,
(include suite or floor)
PRIMARY CONTACT
Who should we call /write concerning this project?
Address:! fj fil's 01 City44 /' 4110VIAOState 644 Zip "zz
Office Phone: - , rCell #,M- &y2 Fax # E -mail iwf E 468z 9S ✓yG �i
o r
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name /Type: an M da 01-14 &eaa Ks
L11_k 1" 51 0 t"1r6
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:
*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 be §4f my knowledgej have read the conditions of approval, and I understand them, and that I will abid by them.
AA
4 V/ 4
Signature °®-- -Punted te'44w'I
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
d
Intake to complete the following: Reviewer to complete the following:
Y / N Square footage of Use:
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet. O / N
Permitted as: oVt� ���. <s✓
Y/N 1
Will there be food preparation? Under Section: A, Z
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 well or ter?
If private well, provide He ent form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applie
Is parcel on septic or pu is se
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 #
7nnina to emmnlPfP fhP fnllnwina-
Parking formula:
Required spaces:
Y/N
Items to be verified in the field:
Inspector:
Notes:
Date:
Violations:
Y/O
If so, List:
Proffers:
Y/N
If so, List: 01-15
Variance:
Y 1
If so, List:
SP's:
Y/M
If so,List:
Clearances:
SDP's
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, z PLy i'~ C U tyz ,
[County application name and number]
was provided to p3p the owner of record of Tax Map
[name(s) of the record owne s f the parcel]
and Parcel Number 0"" &)0000&0:1i (~} a by delivering a copy of the application in the
manner identified below:
V Hand delivering a copy of the application to `9 y tlJ(�+� CGS Pa-^j\%�'+
[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 8Aai/lj_
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 in 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
M 1 ck aj o S,Ja+ Z
Print Applicant Name
b /a( /1W z
Date
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