HomeMy WebLinkAboutCLE201200224 Legacy Document 2012-10-26In
Application for Zonxn Cieara
PLEASE REVIEW ALL 3 SHEETS
OFFICE U1q f LY
Cheek # Date:
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Receipt
PARCEL INFORMAT' - (� ,�,� / l j�a'^ D
y-�j ° v L�xisting Zoi(iug�;'� �! i'v'(�.
Tax Map and Parcel, r 1
Pat-eel Owner: ('_� 4 1
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Parcel Address: -/
- - (include suite or floor)
PRIMARY CONTACT n `
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Who should the coliltvrite concerning (his project? �1X� �� rrvj a
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f V4 City �h 1 ilustate V Zip
Address., �
Office Phone: Cell # gN ax # R -mail
APPLICANT IN;F`ORMATION
Checlt any that apply; Change of ownership Change of use Change of name Net}' business
BushtessNorne/Type ;,
Previous Business on this site
Describe the proposed business including use, number of employees, number ofshifts, available parldngspnees, number of
vehicles, and any addltional Information that you can provide;
#'this Clearance will only be valid on the parcel for which it is approved. Ifyou change, intensify or move tJte 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 ofapproval`, aanndd I understand them, aand that I will abide by them.
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SIgnature Printed yV/�i�Y/lL !V( \ 1/yal/
APPROVAL INFORMATION
Approved as proposed [ ] Approved with conditions [ ] Denied
[ ] Backflow prevention device and /or current test data needed for this site. Contact ACSA, 977 -9511, x117.
[ ] No physical site inspection has been done for this clearairce. Therefore, it is not a determination ofcompliance with the existing
site plan,
[ ] This site complies with the site plan as of this date.
Notes:
Building Official Dale l o f o t -�
Zoning Official ate �� � ^✓
Qther Official Datc 3
ounty ombernarle Department of Cosmnunity Develophient
4ol McIntire Road Charlottesville, VA 22902 Voice: (434)•296- 5832,'ax: (434) 972 -4126
Revised 7/1/2011 Page 2 of 3
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Tirtalce {o complete {]te following;
to complete the follo�tving,
Y (� Square footage of Use:
Is use to Ll, M or PDIp zoning? If so, give applicant a Certified Y / N
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Engineer's Report (CER) packet. Permitted as:
(�jj N Under Scction: j
1�tid1 there be food preparation?
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;onilt to corn fete the followiu prof£ t
ti�ioi t ns: Y / 1
Y ! �}
If so, List:
If so, List:
SP`s�:(�
vnri Y / 'l%
Y1
if so, List:
if so, tst:
Clenranees:
SDP's
001 —,1 l
Revised 7/l/201I page of
If so, give applicant a Health Department form.
Zoning review can not begin until we receive approval from Health
Supplementary regulations section:
Dept, rAX DATE��-
V. �p
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Circle the one that applies
Parking formula: �
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Is parcel on private Well �pu ?
Ht form.
- -
If private we}1, provide
Zoni ng review can not begin until we receive approval from Health
Required spaces:
Dept. rAX DATE `—
Y /
r ified in the Feld:
IteEzve
Circle the one that ap }'
Is parcel on septic or er?
Y /N
1
Will you be puttIng up a new s }gn of any kind? If so, obtain proper
Date:
'
Sign permit.
Inspector :
Permit #
Notes
Y /
Wi }i ere be any new construction or renovations?
�
If so, obtain the proper Permit.
Permit # �—
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;onilt to corn fete the followiu prof£ t
ti�ioi t ns: Y / 1
Y ! �}
If so, List:
If so, List:
SP`s�:(�
vnri Y / 'l%
Y1
if so, List:
if so, tst:
Clenranees:
SDP's
001 —,1 l
Revised 7/l/201I page of
a � �
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CERTIFICATION THAT LANDOWNER
NOTICE
APPLICATION HAS BE, EN PROVIDED TO THE
-- -- - - - - Thlsfonn_trttist accontptut), torilttg appllcutlorts (Haute occitpritioti, Zoning clearance, Zoning
Atht:tlrisirtilor Deternilrrtttions or Appeals, Sig,, Pertttits, Building 1'erml(s) if the applicttliott -!s riot the
o}vtten
I certify that notice of the application,
6L-, Z -p12= �-�l
[County application name and number)
was provided to . e� �" GGG the owner of record of Tax Map
[name(s) of the record owi ers of the parcel]
by delivering a copy of the application in the
and Parcel Number
manner identified below:
zI4 C/
.ate Gi t
Hand delivering a copy of the application to [Name o f 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]
an
Date
Mailing a copy of the application to _
[Narne 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]
Oil r �, to the following address:
Date
[address; written notice mailed to the owner at tite last known address of the owner as shown on
t
he current real estate tax assessment books or current real estate tax assessment records satisfies
this requirement].
Signat%ofA ca nt
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_Val� Prinf ApplicantName
Date
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