HomeMy WebLinkAboutCLE201300026 Legacy Document 2013-03-29�') L 4 cm I -V
Application for Zonin Clearance
CLE # 0 ' L'��
OFFICE USE NI,
(D 2-11-1V
PLEASE REVIEW ALL 3 SHEETS
Check # Date:
Receipt # Staff: rr,) /1 1
PARCEL INFORMATION
Tax Map and Parcel: /T/l') /{ Existing Zoning
Parcel Owner: / ,✓%�C/��{°, � �f�� ZL(Vo
Parcel AddressJa� —&z2 5/; 5z&/6 AV City( , /Y /�' /%����J / Z�tate Zip 9G/
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project
/?
Address :1(Q)P&'A1YA1�& i )W tyiC / bzy State Zip
Office Phone: l' Cell # Fax
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name /TypeL'Y7, _5,/'/?J�L�� l i/Y/l/I� Zyl�'� �� ✓� %��'f15��1".��
7-
Previous Business on this site Ame,
Describe the proposed business including use, number of employees number of shifts, available parking spaces, n b of
iye,�, infor. that Ye C/ S�
ve and any additional ation ou can provide: c� /?o
; —
�P ,
'This Clearance will only be valid on the parc6l for which it is approved. 4f you change, intensify or ni ve the use to a nZw 1 cation, anew 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 myknowledge. I have read the conditions of approval, and I understand them, and that will abide by them.
Signature �/ %J %�/% �a//y/%%��/ Printed c /(
APPROVAL INFORMATION
[mac] 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 ).j -I f3
Zoning Official sl/� Date ��12, o /3
Other Official Date
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
Revised 7/1/2011 Page 2 of 3
W
Intake to complete the following:
Y/N
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y/N
Wil 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 private well o public water?
If private well, provide Health Departmen orm.
Zoning review can not begin until . we receive approval from Health
Dept. FAX DATE
Circle the one that ap 'es
Is parcel on septic public sewer?
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign pern t_
Permit # t
Y/N
Will there be any new constriction or renovations?
If so, obtain the pro er Pe u .
Permit # I n
Zoning to complete the following:
Reviewer to complete the following:
Square footage of Use:
Q/ N f
Permitted. as: k4'g 1 � 1
Under Section: &4. T/qc'- C y
Supplementary regulations section:
Parking formula: �J.
S 000
Required spaces: 31
Y/N
Items to be verified in the field:
Inspector : Date:
Notes:
Violations:
Y'TM
If so, ist:
Proffers:
&/ N
If so, List:
nor -3
Vari nce:
Y /`
If so List:
SP's:
Y/0
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 (Hoare 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, Zolii ;qa
[Cjomy application name and. number]
` ,
was provided to //' /�� «�. Z, � r ,(--a the owner of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number / /pJ%J k �'} i/ , IM 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
Date
Mailing a copy of the application to eA4
[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 W1QZ% 1cZi% ? 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].
igi ture of Applicant
Print Applicant Name
�7
Date