HomeMy WebLinkAboutCLE201200242 Legacy Document 2012-11-28d
_.... Applica.tion for Zonin Clearance
CLE #
OFFICE USE O t
PLEASE REVIEW ALL 3 SBEETS Check # I& Date:
Receipt # Staff:
PARCEL INFORMATION, S
Tnx Map and Parcel: Existing Zoning
Parcel Owner'J�
! Cl�l °�� te d Zipago
Parcel Address: 7R City Sta
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning' this project? -SCPR +�� � � � S
Address: 1� (J L iti G% /t/ 066-7 �` City L nr C-7NState V4 . Zip
Office Phone: (203 Sari Cell # ~ 2Syrot {Fax # E -mail
APPLICANT INFOR.MA
Check any that apply:__ Change of ownership Change of use Change of name New business
Business NametType: j • 6• %:;
t� "C C �' .� -S C�1 �r 5�t-i i�1 tZ
.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: --Tiff tA e G iAO,6'�,r.w•a.
E t1 p i. v YE)i S l orr- 3 rs / t) B41? k%lwC -_SL► S F !Z t'a" ;4
'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 bythern.
Signature Printed Yn
APPROVAL INFORMATION
[ J Approved as proposed [ Approved with conditions [ Denied
[ J Backflow prevention device and/or current test data needed for this site. Contact ACSA, 977 - 4511, xl 17.
[ ] No physical site inspection has been done for this clearance. 'Therefore, it is note determination of compliance with the existing
site plan,
[ j This site complies with the site plan as of this date.
Notes:
Building Official
Zoning Official
Other Official
Date-'
Date I � 1
County of Albemarle Department of Community Development
401 McIntire Road Char•Inttesville, VA 22902 Voice: (434) 296 -5832 r, six: (434) 9724126
Revised 711/201,11 Page 2 of .3
G �h
Intake to complete the following:
Y /
Is us LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Will`tlfere 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
Reviewer to complete the following:
Square footage of Use:
j) /N y
Permitted
Under Section: AX ,,. , il( t1Gi S
Supplementary regulations section:
Circle the one that applies --- rarxmg tormuia:
Is parcel on private well or public water?
If private well, provide Heal, h De rtment form.
Zoning review can not begin until we receive approval from Health Required spaces:
Dept. FAX DATE
Circle the one that applie
Is parcel on septic or G is sewer
Y/N
Will you be putting up a new sign of any kind?
Sign permit.
Permit #
Y/N
Item to be verified in the field:
If so, obtain proper
Inspector : Date:
I, / N Notes:
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zonin to com lete the followin
Violations:
�. /N
q
f so, List: /A
Proffers:
Y/q
If so, st:
Variance:
Y/N
If so, List:
S 's:
(V /N
If so, List:
Clearances:
SDP's
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, �1 ✓��-�✓
[C my app ication name and number]
was provided to 5l/Or pzx(' 61c--�- hql� ° the owner of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number
manner identified below:
GiX 13 s 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
VA - � e hl, , c r-5
[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 1 / f 5 ',2 G % Z' to the following address:
Date
V^
[address; written notice mailed to the owner at the lasf 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].
Sigpdture f Applicant
yosC -P# 4>950EZQ/4Sly
Print Applicant Name
Li /,:02 -) 2
Date