HomeMy WebLinkAboutCLE201200237 Legacy Document 2012-11-28pplzca on or Zonxn Clearance
��
ter% ./
CLE a 3G ! ,r0 i
c�✓�
�' 'fin f
37RCnN
OFFICE USE ONLY
PLEASE RE' VIE' W ALL 3 SHEETS
Check # stte:
Receipt # Staff:
PARCEL INFORMATION
SC}d G
Tax Map and Parcel, 04 _-�} _.a-d. Cj I Existing Zoning
Parcel Owner;
zC3iq .,.r'tr7h IeJOLU { e A tl. City t"'t3" U i UL. ' State 11 Zip Z2 Id I
Parcel Address: ty.
(include suite or floor)
PRIMARY CONTACT
Who should we call /write concerning this project "�
Address: 3L7 L P P t,,Nt. 0-09'? t2j City CO ' yt LLL— State
Office Phone: U 2'9(' - &U 31 Cell # Fax # E -mail k_W A C-7 CIA- " }
APPLICANT INFORMATION
Check any that apply; Change of ownershipj,� Change? of use Change of name New business
Aftw,+
Business Name/Type-
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:
*T'his Clearance will only be valid on the parcel for which it is approved. If you change, intensify or move the ase to anew 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 by there.
Printed
Signature s
APPROVAL INFORMATION
>1 Approved as proposed [ Approved with conditions [ Denied
[ j 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 T ( ( l
Zoning Official Date 1
Other Official Date �/" Z7r-/�z-
County of Albemarie Department of �_ommunuy lievemp,,,enc
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296- 5832.F'ax: (434) 972 -4126
Revised 7/1/2011 Page 2 of
J
Intake to complete the following:
Reviewer to complete the following:
Y ICN
Square footage of Use:
Is us in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
/ N /
Oermitted as:n
Willre be food preparation?
Under Section:
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 r pYiD" 'ter?
If private well, provide H alth Depart ent form.
Parking formula:
Zoning review can not begin u we receive approval from Health
Required spaces:
Dept. FAX DATE
SDP's
Y/N
Circle the one that applies
Is parcel on septic u lic- r?
Items to be verified in the field:
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Inspector : Date:
Y / N
Notes:
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
7 fn nmm ln +n fhn fnllnwina-
,iVolations:
6)1N
If so, List: l J
Proffers:
ly /
If so, st:
Variance:
Y/N
If so, List:
SP's:
Y
If so, ►st:
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3
CERTIFICATION THAT NOTICE OF THE
APPLICATION HAS BEEN PROVIDED TO THE LANDOWNER
This forni 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,
[County application name and number]
was provided to ��� Pe 2-x'11 L-S, L the owner of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number 0`1 ` t�U —�L --COQ — C t by delivering a copy of the application in the
manner identified below:
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 ! ��'�' �'-ti' �` �� `t 'v "z 1 to the following address:
Date
1 _
7� 27 CH-AA-L-.0,T?U1s- d,L.c.v L!H- Z"zcl 0G
[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
I
<c14UTL-7 -:Jr C./!�C -le rU'
Print Applicant Name
Date