HomeMy WebLinkAboutCLE201200124 Legacy Document 2012-12-27Application for Z!![[onl ing Clearance
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CLE # � 0 1 Z- I�
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PLEASE REVIEW ALL 3 SHEETS
OFFICE USE ON L
Check # 2 2 Date: (P
r76 tZ Staff:
Receipt #
PARCEL INFORMATION
Tax Map and Parcel: 0 61 W o — o-2 ` 0 0 0 20 D , Pcm-W C_ Existing Zoning �'-
Parcel Owner: R Mb �t`o?a rrt[ a4 , 111C _
Pa► cel Address: 1 qS S PiiM inn o 1 1 ref , City C 1 J' State VA Zip �-2q o I
(include suite or floor)
PRIMARY CONTACT H u 0
Who should we call /write concerning this projec t?
l-a� e- ,2 q
Address: 110 (i t,l,tuns I'�'[rywAta [, City C�"rl° ' 1 Atate V A Zip
Office Phone: 4-1 03 Cell # ¢4 $25 4.90 Fax # E -mail
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use __.K __Change of name New business
Business Name /Type;
Previous Business on this site b CJ��S 1 P
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: Asia', q'v CA-r'"►i ab "e- LUL L 4-' "' V10,9U,0
2't%:vw ?)o Ccvr_ i SPr c� , q�C C�"LI��VY '�Mu•Gl<
*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 by them.
Signature L d-=� (ice-- Printed U; _ n
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 fo
Zoning Official Date���% /�`� /�
Other Official Date
County of Albemarle Department of Community l)eve►opment
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
Revised 7/1/2011 Page 2 of
Intake to complete the following:
Y /�
in Is u LI, III or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y/N
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 or p11- "'� er?
If private well, provide Heal&-Dzparfrnent form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that app li`e
Is parcel on septic or is sewe ?
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
W/N
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit # -x y / Z
7-- +^ nmmnla +a +ha fnllnwina.
Reviewer to complete the following:
Square footage of Use:
QlN (�
Permitted as: �D�rX S�ore�
Under Section:
Supplementary regulations section:
Parking formula:
2s
Required spaces:
Y/N
Items to be verified in the field:
Inspector : Date:
Notes:
LiUll XIALr4 LV Iry 111 A- r
Vlolations:
/N
If so, List:
Proffers:
YA
If so' ist:
T
Vari ce:
Y/N
If soo' List:
SP's
Y
If
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3
V
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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,
[County application name and number]
was provided to P'I �r o pe�i �� , hC the owner of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number 0 61 W 0 — o 2 ~ o /j — b u 2 b b by delivering a copy of the application in the
manner identified below:
/ 4 t i 1✓ Hid k, s-t
.! Hand delivering a copy of the application to C . Cltiar twbbL-i v, f l9. V A .zi ?o2
[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
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
144 0 1 O*L0
Print Applicant Name
4 /4-112
Date
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