HomeMy WebLinkAboutCLE201200249 Legacy Document 2013-01-11• 1 to ) V v I J., - v ..,.. -
Application for Zonin Clearance
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0FFIC>c uY O Y
PLEASE REVIEW ALL 3 SHEETS
Checic # '
Receipt # Staff;
PARCEL INFORMATION
1 W ` 3 " 1 Existing Zonin
Tax Map and Parcel; I Q t7
Parcel Owner.
Pnrcol Address:26 5- cJ City'�g %5V(UAtatc --Zip AAW
(include suite or floor)
PRIMARY CONTACT �.-
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Who should we call /write concerning this project?
V i4 �.o J
Address City Sta te Zip
2 0 H I VK t9t�7"If tthlNG,
Office Phone. C� Cell # D'lt�Fax # E-mail St Ua►-' S��
APPLICANT INFORMATION
Check any that apply; Change of ownershlp Cllnnge of use Change of name New business
Business Name/Type;
Previous Business on this site
Describe the proposed business Including use, number of employees) numbw of shifts avails ble rldng spaees, number of
2�t" t 5 4T- - 'syw 1t:3
vehicles, and any additional information that you can provide; & *tla �5'�r ,
*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
best I have read the conditions of approval, and I understand them, and that I will abide by them.
is true and acc e o th o y wledge.
Signature Printed„ A'&ib 6rFM40
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 tite site plan as of this date.
Notes;
— Dated_!
Building Official
/�(?
Zoning Official / Date 7/�3
0 Date
Other Official t/,
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401 Mcluth a Road Charlottesville, VA 22902 Voice; (434) 296- 5$32lraxt (434) 972 -4126
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L Revised 7/1I20I 1 Page 2 of 3
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Intake to complete the followhig:
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Is «se in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
J/ fir.
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 OA244a y
Circle the one that applies
Is parcel on private well ub� e w er?
If private well, provide Health Department form.
Zoning review can not begin until we receive approval from Health
Dept, FAR DATB
Circle the one that applies
1s parcel on septic or public sewer?
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y/N
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit Il / 2— X29/ 461
Reyieiyex• to complete the following:
Square footage of Use: -11b
(� / N
Permitted as: Pq�"—��i e:5,)A ��✓
Under Section: U,A(- er � y�
Supplementary regulations section:
Parking formula:
Required spaces:
Y /I�I
Items to be verifiod in the field:
Inspector : Date:
Notes:
GU /ll {l lV tiV+ +l JIGIG tl +c Av++v+r++a
Violations:
Y
If so List:
Proffers:
/N
f so, List:
2 em-- I/
Varlance:
Y/6
If so, List:.
SP's:
Y/(
If so, List:
Clen rnnees:
SDP's
U S_/ y2 .
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Revised 7/1/2011 Page of
CERTIFICATION THAT NOTICE OF THE
APPLICATION HAS BEEN PROVIDED TO THE LANDOWNER
Tltlsforin must accompany zorriug trpplieatlous (Home occupation, Zoning Clearance, Zoning
Adn:lnlsiratorDeternrinalions orAppeals, Sign Permits, B01(ling Permits) if the application is not the
owners
i certify that notice of the application,
[County application name and number]
was provided to the owner of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number
manner identified below:
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
[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 t �p to the following address:
Dat
[address; written notice mailed to the owner at the last known address of the owner as snown on
the current real estate tax assessment books or current real estate tax assessment records satisfies
this requirement].
Signature of Ap },
Print Applicant Name
L
Date