HomeMy WebLinkAboutCLE201300010 Legacy Document 2013-02-19Application for Zoning Clearance
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PLEASE REVIEW ALL 3 SHEETS
OFFICE USE QN Y i -Ito, )
Check # T Date: I
7 Staff:
Receipt #
PARCEL INFORMAT N11 V��,t Af�
Tax Map and Parcel: t� Existing Zoning
Parcel Owner:
Parcel Address -t!, �jQ� %�• C►ty State V Zip
(include suite or floor)
PRIMARY CONTACT
Who should we call /write concerning this project9 ka 2 (�- L) y �S
Address : 7)/(2 Al � City A—,F;z,-4Al' S tate 11A Zip 4j U
Office Phone: (# —� Fax # E -mail ';
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
p
Business Name /Type: / 7.1 e
Previous Business on this site
Describe the proposed business including use, number of employees, number of shifts, available parking spaces, number of
vehi es, and any additional information tha you can provide: !
l—A-�
*This Clear nce 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 kn wledge. I have read the conditions of approval, an , I understand them, and that I will abide by them.
Signature �/ Printed
APPROVAL INFORMATION
>c] 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 f 1 �L-a f `3
Zoning Official 4. Date
Other Official Date
County of Albemarle Department of uommunny lieveiupmerrL
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
Revised 7/1/2011 Page 2 of 3
Inta a to complete the following:
Y/N
Is a in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
4Y N
.1 re 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- pr5ivate wel or public water?
If private �el.l,..pro-vrde Health Department form.
Zoning review can not begin until we receive approval from Health
Dept, FAX DATE
Circle the one -t plies
Is parcel on rptic o public sewer?
Y/N
ou be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y/N
W t re be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
7nnina to emmnlPtP the fnllnwinu:
Reviewer to complete the following:
Square footage of Use: 5 / � /a
/N
,-mitted as: Arr� 5�A AJ
Under Section:
Supplementary regulations section:
Parking 4,,-,
Required spaces:
Y/
Item be verified in the field:
Inspector : Date:
Notes: p /
OG✓,4 /c,7 g (S Alle
Violations:
O/N
If so, List:
Proffers:
YA
If so, ist:
Vari nce:
Y /`)I
If so, List:
SP's:
Y/
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,
A�� / [County application name and number]
was provided to —�=A, '�AJ the owner of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number
manne r identified below:
' -, / Hand delivering a copy of the application to
by delivering a copy of the application in the
[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].
G'L'�'C �'�
KU !�" ff
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ignature of Applicant . ` C/
[Tint Applicant Name `-1
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Date
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