HomeMy WebLinkAboutCLE201200223 Legacy Document 2014-04-25Application for Zoning Clearance
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PLEASE REVIEW ALL 3 SHEETS
OrrICB USE ONLY
Check # Date;
Receipt # Staff;
PARCEL INFORMATWN
Tax Map and Parcel; 000 "' — bid ` 0 35' xisting Zoning._r
Owner ;
Pa reel
1
1_
city 47 U i % /L°.- state Zip
Parcel Address: jam, -�
(include suite or floor)
PRIMARY CONTACT �/ r
Who should we call /write concerning this project? —/,I
City ��/4'f m /tP Stnte ZipaA�E3
Address
# E -mail
Office Phone: L Cell #G x
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name ew business
Business Name/Type: 1 --
Previous Business on this site l� 4�
Describe the proposed"business including use, number of employees number of shifts, available par 'ng spaces, number of
t
vehicles, and any additional information that ypu can rovide: .-S t✓
*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
is true and accurate to the best of my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature Printed Zbr^� /tom
APPROVAL INFORMATION
Approved as proposed [ ]Approved with conditions ed
[ ] Backflow prevention device and /or current test data needed for this site. Contact ACSA, 977 -4*,OIP
[ ] 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. r ayw v/ � f�
Notes:
Building Official ., Date tor� 1 2 %
/�� /��
Zoning Official Date
Other Official Date
County or Albemarle tpeparunum vi %- UA,uuuuu.y —.,. N..•....
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
Revised 7/1/2011 Page 2 of
�a e,
Int,,:ke to complete the following:
n/N
is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y/PWill there be food preparation?
If so, give applicant a Health Department form.
_Zoning review can not begin until we receive approval from Health
Dept,'" AX DATE
Circle the one that applies
Is parcel on private well or Qun titer?
If private. well, provide Heal art: nt form.
p
Zoning review can not begin -u receive approval from Health
Dept. TAX DATE
Circle the one that appli
Is parcel on septic or ublic s wer7
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 #
LL- l
Reviewer to complete the following:
Square footage of Use: 1j-2(>
� /N
ennittedas: 1n/i
Under Section:. _ 2�r
Supplementary regulations section:
Parking formula: zu
Required spaces:
Y/N
Items to be verified in the field:
Inspector
Notes:
Date:
GOning w culls low ll1G 1V11V17111 .
Viola ons:
Y/V
If so, List:
Proff s:
Y/�
If so, ist:
Variance:
YI
If so, st:
SP's:
Y/N
If so, List:
Clearances:
SDP's
Revised 7/1/2011 Page 3 of
i
y I
a
CER.TI[FTCATION THAT NOTICE OF .Y..iJE ���J����7�
APPLICATION HAS BEEN PROBED TO THE LANDOWNER
�,�ER
This form must accomwany zoning applications (Home Occupation, Zoning Marance, Zoning
Administrator Determinations or Appeals, S`igr: Permits, BuWngPermits) ff the application is not the
owner.
I certify that notice of the applicati on,
[Co application name and number]
was provided to 1� , Z_ L G the owner of record of Tax Map
[narcie(s) of f he record owners of the parcel]
and Parcel Number -q:%'00 by deliveering a copy ofthe application in the
manner identified below:
Hand delivering a copy of the application to a N e, Sh d Uj
[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
i [Nanme 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 i
[address; written notice mailed. tathe owner at the last known. address of the owner as shown on
the current reaj estate tax assessment books or current real estate tax assessment records satisfies
This reauirementl.
V Q
signature of Applicant —�
far,a_0ae,--
Print Applica/ntt Name
0 -
Date
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