HomeMy WebLinkAboutHO201300012 Legacy Document 2013-01-28Cwrm' o Al,(wamm1 6-V&5
Application for Zoning Clearance1�'��
CLE # W 15 " 12-
OFFICE USONLY
Date: L L
PLEASE REVIEW ALL 3 SHEETS
Check # l
Receipt # r Staff:
PARCEL INFORMATION VY-I�� /�iGNr�O �DM�op2�i�L
Existing Zoning
Tax Map and Parcel:
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Parcel Owner: ��IfislAA14 �ad
Parcel Address: 506 ��U✓�% � /'L� t��Lr City Qi1KW/7j6 11,C State 011 Zip jifil
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project?
Address : 16-0' ��✓�� %+ f/� 1 �I/d�%1City CfiWW%%��111,4L&'State VA Zip Z2%��
Office Phone: U �93 0471 Cell %Yr Fax #7-43 ZVM E-mail i�N%�J'��� d��✓G"0/1i
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
11 ✓��(�� �p/��(/T�j GSCA'm %%V'Vllw �G� 1'VIJP
Business Name/Type:
Previous Business on this site ArW eV i'6,F1', (e17�W
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: 1,,V,&*' /�ONVT.f STO�'�', %SEM%�6�t/E S o x.511115-
1-15W6E f'/�i2k%N6 Lyi GDS S/for il/G Zb�T1??
*This Clearance will only be valid on the parcel for which it is proved. 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 t er's er is o o use the space indicated on this application. I also certify that the information provided
is true and accurate to the best oyh read the conditions of approval, and I understand them, and that I will abide by them.
Signature Printed Af/I{l1d1P
APPROVAL J FORMATION
[ ] 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 I Date
Zoning Official Date
Other Official Date
County of Albemarle Department of uommumty ueveiopment
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (434) 972-4126
Revised 7/1/2011 Page 2 of 3
Intake to complete the following: Reviewer to complete the following:
Y / N Square footage of Use:
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet. Y / N
Permitted as:
Y/N
Will there 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 Parking formula:
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 Required spaces:
Dept. FAX DATE
Circle the one that applies
Is parcel on septic or public sewer?
Y/N
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:
Nntrc
Y/N
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Violations:
Y/N
If so, List:
Proffers:
Y/N
If so, List:
Variance:
Y/N
If so, List:
SP's:
Y/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,
[County application name and number]
was provided to if IW1411'0 81M1¢/ tillf, - #ARA/ 6M the owner of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number W-/10 by delivering a copy of the application in the
manner identified below:
_X Hand delivering a copy of the application to 414VWI� 40/X/ /'l G NOX i6reO
[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 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].
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Print Applicant ai
f�U�Z
Date