HomeMy WebLinkAboutCLE201200189 Legacy Document 2012-10-12Application f r Zoning Clearance'°
F
CLE #
�'jliGf7.1A
OFFICE UA O LY
PLEASE REVIEW ALL 3 SHEETS
Check# Date: d
Receipt # Staff:
PARCEL INFORMAT19N C", Tax Map and Parcel: Existing Zoning P;,41
Parcel Owner: V
Parcel Address: �����`� City "l�P�T� State 117 Zip 201
(include suite or floor)
PRIMARY CONTACT
Who should we call /write concerning this project?
Address : / ® /d�J' �_ Cit e/ State Zip �®
Office Phone: Fax # E -mail i gds_
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use of name New business
r �C/h!ange
Business Name/Type: 4L/14&-Ach ! /GPdI 4' abrMa J034 &Ct2Lr-
Previous Business on this site L,JC�^ I J f ICKr —
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: Q.wl C7 ko' v O
*This Clearance will only be valid on the parcel for which it is approved. Ifyou change, intensify or move the use to a new location, anew 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 knowle ave read the conditions of approval, and I understand them, and that 1 wil bide by them.
Signature Printed ! -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
Zoning Official Date
Other Official 0 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:
YGN
Is use in LI, HI or PDIP zoning?
Engineer's Report (CER) packet.
If so, give applicant a Certified
Y&
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 uiipirtmRnit If private well, pr ovide Health form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that appl
Is parcel on septic or ublic sewer9
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
YIN
Will there be any new construction or renovations?
If it 4 ' j e pe. �
Permit #
7nninrs to rmmniete the fnlinwinor:
Reviewer to complete the following:
Square footage of Use: /t), o 00
N
Permitted as: M ' cA 4o
Under Section: 2- 5 A � • f
Supplementary regulations section:
Parking formula:
Required spaces: f ,
Y/N `T
Items to be verified in the field:
Inspector : Date:
Notes:
VM ans:
Y
If , st:
Proffers:
b/ N
If so, List:
Variance:
Y/
If sot:
SP'
Y N
If so, ist:
Clearances:
SDP's
Revised 7/1/2011 Page 3 of
CERTIFICATION TION THA T NOTICE OF THE
APPLICATION HAS BEE] PRO VIDED TO THE LANDOWNER
T his form ntust accompany zoning applications (Horne 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(h i V\ C U� �
[County M )plication name and number]
was provided to JJ the owner of record of Tax Map
[namc(s) of the record owi ers of the parcel]
and Parcel Number 0'7b6000000,31 k O by delivering a copy of the application in the
manner identified below: fj r
delivering a copy of the application to P� 1�7k i L.J S
[Name of the record eAwner 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 S / d--1 Z/
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
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