HomeMy WebLinkAboutCLE201300001 Legacy Document 2013-01-14Application for .honing Clearance
QFFiCE USE,ONI,Y
PLEASE REVIEW ALL 3 SHEETS Check #
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Receipt # ` - Staff: :_� --
PARCEL INFORMATION
Tax Map and Parcel: _ 0 324 0 - o o - O V - O (7 E 1 Existing zoning L =,
Parcel Owner: o b 1 e N N C b m a„ [. Lc-
Parcel Address: / 7 Doi le-q- /J /v DCity ��� 1��%�� State � . Zip Z Z///
(include suite or floor)
PRIMARY CONTACT
/7
Who should we call/write concerning this protect?
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Address: d �t°s�t 6 W 00 Cit e State � • Z �
�a / Ave. 3GL1�e y eh Wl l/ zip�7
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Office Phone: Cell # dd ' IL T f:Fax # �1 l— I Z T �E -mail loll 1• D W A Re� (� I� F3
APPLICANT INFORMATION
Check any that apply: Change of ownershijp� Change of use Change of name New business
13usinessNamefType: �( e ( �J /���d
Previous Business on this site f e Se av i Ge s
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: a PiG'CP t4 �
4:: P (l� I e tf� C 1rJD p ys �`G ���
�T4_
"This Clearance will only be valid on the parcel for which it is approved. Il'you change, intensify or move the use to anew location, a new Zoning
Clearance will be required.
I hereby certify that I o-mi or have the o- mier's percussion to use the Space indicated on this application. 1 also certify that the information provided
is true and accurat o the best of my knowledoc. I have react the conditions of approval, and 1 cuiderstand them, and that i will abide by them.
Signature Printed ve y
APPROtYAL INFORMATION
Approved as proposed ( ] Approved %with conditions [ l Denied
[ ] Back-flow prevention device and/or current test data needed for this site. Contact ACSA, 977 -4511, xl l7,
[ ] No physical site inspection has been done for this clearance. Therefore, it is not a determination ol'compliance with the existing
site plan.
J ] This site complies with the site plan as of this date,
Notes:
Building Official Date ( ( 3
Zoning Official Date
Other Of eial Date
County ofAlbemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 2965832 Fax: (434) 972 -4126
Revised 7/1/2011 Page 2 of 3
"ID 4awt
Qom-,
Intake to complete the following:
Ctier I, HI or PD[P zoning? [f sa, give applicant a Certified
Engi Report (CER) packet.
Y / N�
Wilt ere 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 public water?
If private well, provide 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 septic or public sewer?
Y l
Wi u be putting up a new sign of any kind? 11'so, obtain proper
Sign permit.
Permit #
Y /GN )
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the following:
Reviewer to complete the following:
Square footage of Use:._
6?/N
Permitted as: - Q.Q'
Under Section: 21.2
Supplementary regulations section:
Parking formula:
Required spaces:
Y1.
Items to be verified in the field:
Inspector • Date:
Notes-
Violations:
If / (R)
If so, tst:
Proffers:
y nN
if tsi:
Varl Lfl C:
I /1
lf so, List:
SPr .
y
tf�sc t.
Clearances:
SDP's
Revised 711 /2011 Page 3 of
CERTIFICATION THAT NOTICE OF THE
APPLICATION HAS BEEN PROVIDED TO THE LANDOWNER
This form must accompany zoning applications (Nome occupation, Zoning Clearunce, nil
Administrator Determinations or Appeals, Sign Permits, Building Permits) if theapplicatioll is not tlae
owner.
I certify that notice of the application, G• o N t x % 6 led tz a N a—
[County application name and number]
was provided to Aa41e Ann) db meaju i U. c- the owner of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number 0,3Z DO . o o - a o _p� E' 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
[late
V Mailing a copy of the application to J&.6"le.4,nn�vo4lawY L. L c--
[Naene of the record owner if the reco d owner is a person;
if the owner of record is an entity, identity the recipient of the record and the recipient's title or
office for that entity]
on /- :3 — Z &,/ 3 to the following address:
Date
[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 of61Splicant
Print Applicant Name
Date —
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