HomeMy WebLinkAboutCLE201300058 Legacy Document 2013-04-24Application for Zoning Clearance
CLE # _Z8i 5 -'�
(1,
PLEASE REVIEW ALL 3 SHEETS
OFFICE U 1 0 rILY
Check# UJW Date: _�>29`o
Receipt # Staff: r
PARCEL INFORMATO t _ 4C,
Tax Map and Parcel: ' ( / Existing Zoning
Parcel Owner:
Parcel Address: lo t L. L Kno— City l_ �iXF /--State ZiQ),
(include suite or floor)
PRIMARY CONTACT
Who should we call /write concerning this project?
Address M67, , 6 6j k ' City frj Jp State
Office Phone: (_� Cell #i�(9•�i�% J&YAFax # E -mail
APPLICANT INFORM
Check any that apply• Change of ership Change of use Change of name w business
Business Name /Type: L % A4M "
Previous Business on this site �J
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: (`_(M 0 r A to (° (o ern L2d-
*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 acc r-at to the best of my wl dgef. I have read the conditions of appro I and I understand ahem, and that I will abide by them.
Si nature " O �j Printed TL A 0
g
APPROVAL INFORMATION
[XA'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 d te.
Notes: AM Y
yT 'li C a
Building Official Date __3
Zoning Official J., Date r
Other Official Date
County of Albemarle Department of Communi Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
Devised 7/1/2011 Page 2 of 3
Intake to complete the following:
Y
Is Loin LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
N
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 60-�c Is p arcel 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/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit
Permit #
Y
Wiklb.de be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
fn nnm»lafa 1-hp fnllnwinv- /7
Reviewer to complete the following:
Square footage of Use: 15L4V
•.J /N
Permitted as: unn�, qoj
Under Section:
Supplementary regulations section:
Parking formula: (�
Required spaces:
Y/N
Item t be verified in the field:
Inspector : Date:
1
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:
i
Clearances: A, ,.,
SDP's
Revised 7/1/2011 Page 3 of 3
N
APPLICA
This form must i
Administrator D
owner.
RTIFICATION THAT NOTICE OF THE
N HAS BEEN PROVIDED TO THE LANDOWNER
nany zoning applications (Home Occupation, Zoning Clearance, Zoning
rations or Appeals, Sign Permits, Building Permits) if the application is not the
I certify that notice ofilae application,
[County appli
was provided to \
[name(s) of the re c rd owners of the parcel]
and Parcel Number
manner identified below:
Hand delivering a copy of the appli
person; if the owner of record is an
title or office for that entity]
on
Date
Mailing a copy of the
if the owner of record
office for that entityr]
on
Date I/
iti name and number]
the owner of record of Tax Map
delivering a copy of the application in the
.to
[Name of the record owner if the record owner is a
, identify the recipient of the record and the recipient's
Pication to
[Name of the
an entity, identify the reci
to the following
•d owner if the record owner is a person;
of the record and the recipient's title or
[address;Aritten notice mailed to the owner at the last khowr' address of the owner as shown on
the curdnt real estate tax assessment books or current real estate tax assessment records satisfies
this rg6irement].
Signature of Applicant
Print Applicant Name
Date
V}r,
Application for .Zoning Clearance
���E,z �`�
�
ptrnNlr
PLEASE REVIEW ALL 3 SHEETS
r
OFFICE USE ON Y 1 _Ito,
Check # q Date:
Staff:
Receipt #
PARCEL INFORMAT N l2mat Afaj
Tax Map and Parcel: 1 Existing Zoning
Parcel Owner:
Parcel Address:�O /x 17 17) n City State V Zip
(include suite or floor)
PRIMARY CONTACT
ka
Who should we call /write concerning this project? E C k-) �s
Address.- _J(2 AI � R Cam. City State Zip4
Office Phone: Fax # E -mail
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name /Type:
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 provid d A r
*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 V 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 r Date i I �f
Zoning Official Date
Other Official Date
County of Albemarle Department of Commumiy uevewlimeut,
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
Revised 7/1/2011 Page 2 of 3
�51)
Inttin to complete the following:
Y/
Is u LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y 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- p.r_iva wel or public water?
If private �e1.1,- pxo-vrde Health Department form.
Zoning review can not begin until we receive approval from Health
Dept, FAX DATE
Circle the one4hatoplies
Is parcel on ptic 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 #
7nninrs fn rmmn1PfP fhP fnllnwing-
Reviewer to complete the following:
Square footage of Use: 5 y�
ermitted as: Arm
Under Section:
Supplementary regulations section;
Parking formula;
Required spaces:
Y/
Item be verified in the field:
Inspector
Date:
Notes: 04 ow, I A11Y
Violations:
/N
If so, List:
Proffers:
Y/6
If so, rst:
variance:
Y /em
If so, List:
SP's:..
Y /W
If so, List:
Clearan.ces;____.•��
SDP's ��
Revised 7/1/2011 Page 3 of 3
CERTIFICATION THAT NOTICE OF THE
APPLICATION HAS BEEN PROVIDED TO THE LANDOWNER
Tlzis 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 naive and number]
was provided to, J �a� ��Al the owner of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number
manner 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].
C/ '
ire of Applicant
/C(,I -� �4 C �'
Print
f Applicant Name
/
— /�— /3
Date
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