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Home My WebLink AboutCLE201300079 Legacy Document 2013-05-03fn L� �4 sa ft�in Application for g Clearance��j 612 m CLE OFFICE USE ON G- ✓ PLEASE REVIEW ALL 3 SHEETS Check # Date: Receipt # Staff :C % PARCEL INFORMATN7110 /� a Tax Map and Parcel: - 00 oy -� Z/Q Exiisstting Zoning >d Parcel Owner: // 1///!/`/ 1� ✓/l Address:!/ IL► °' «(�lJ V City �/ ° (� /� L/ V to �' Zip Parcel l� / (include suite or floor) PRIMARY CONTACT Who should we call /write concerning this project? I dress : - - � City C1 (Ay� U111�State U Zip COffice Phone: ( C L Cell # Fax # E -mail (gyp rCds Ca Gi- htQ(Ifr , I APPLICANT INFORMATION Check any that apply: Change of ownership Change of use Change of name New business Business Name /Type:Y) Previous Business on this site &)CArd_� Describe the proposed business including use, number of employees, number of shifts, available parking spaces, number of vehicles, and any additio al information that you can provide: s (��SJ" C' -ce 16) — �J *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 ofmy knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them. Signature A!�P /� Printed ppoycia P, new APPROVAL INFORMATION [ ] 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 �-4 l).-6 f� Zoning Official I (ice n, Date f,1" &�I (-2, Other Official ��'�1' —� �L� 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 �;�-2 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. V i ill there be food preparation? If so, give applicant a Health Department form. Zoning review can not begin pntil we receive l appppproval from Health Dept. FAX DATE �- r o ! Circle the one that appli ._. Is parcel on private w 11 or public ter? If private well, provide ea epartment form. Zoning review can not begin until we receive approval from Health Dept. FAX DATE Circle the one tila ap Is parcel on septic public se r? Y/N Will you be putting up a new sign of any kind? Sign permit. Permit # Reviewer to complete the following: Square footage of Use: /DU v 0/N ermitted as: n t Under Section: t li-- Supplementary regulations section: Parking formula: �5 Required spaces:,�5 r -5 Y/N Items to be verified in the field: If so, obtain proper Inspector : Date: Y / N Notes: Will there be any new construction or renovations? If so, obtain the proper Permit. Permit # 7.nnina to vmmnlPtP the fnllnwinu' Violations: Y/N If so, List: Prof rs: Y/ If so, ist: 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 the owner of record of Tax Map [name(��s)„„ of the reccorrd owners of the parcel] and Parcel Number 0 UG I V� -66 06 - IiM6" 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 [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]. M Signature of Applicant Q?rjK,o � Print Applicant name Y/ 1�� Date ,P",�5 0999 s1 C� K, Q) ,P",�5 0999 o '� sa Application for Z i % -a Q, m n n rn Owner!— Application for Z i % -a Q, I OFFICE May 61 PLEASE REVIEW ALL 3 SHEETS Clieck# Date, I Receipt# ==94q& staff. PARCEL INFORMATI Tax MAP and Parcel, Existing Zoning Owner!— Parcel Parcel Address.jtq city_�� - Zip' (Include suite or floor) CONTACT Who s iouldlywe call/write concerning this project? 60o'HwIlestnte zip ress: city C Ofrice Phone; w �1 qqz Cell # Fax # E-mail APPLICANT INFORMATION Check any that apply,,_ Change of ownership –Z—Cliangeofuse —Cliangeofname New business 4 \ . Business Name/Type-, J ne CA.Muloa Xanr2 'Caybino Previous Business on this site :On� &)-nd C11 M Describe the proposed business Including use, number of employees, number of shifts, available parking spaces, number of vehicles, and any addi�t%111 Information that you clan o, Ide,_!SPW4)q8eP *This Clearance will only be valid on the parcel for which It Is approved, If you change, Intensify or move the use to anew location, anew Zoning Clearance wlI I 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 070YqP P, r',Iernz APPROVAL INFORMATION [ ] 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 zi–(-, n, Zoning Official Date Other Official Date County of Albemarle Department of Community veyelopment 401 McIntire Road Charlottesville, VA 22902 Voice; (434) 296-5832 Fax: (434) 972-4126 Revised 7/1/2011 Page 2 of 3 0