HomeMy WebLinkAboutCLE201300086 Legacy Document 2013-05-06n
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Application for Zoe `gig Clearance 1
CLE #
OFFICE US 0-1
PLEASE REVIEW ALL 3 SHEETS Check # A-1 Date; �J
Receipt # - L Staff; -
PARCEL INFORMATION
Tax Map and Parcel:_ �r, � (� - d ^ !L{ QQ'Arp Existing zoning(
Parcel Owner: ':�ne ( <J6irn�t
Parcel 1lclttr es::�' �IIi J 1�7t "r..,�i.Ly'�Ar dr city _W tc . jar hate r. zip
{include suite or floor)
PRIMARY CONTACT
Who should we c.,dl/wriitee concerning this project?
Address;. !`2L� l;��t . � )�t AY i , ' rc State , Zip `�J!
Office Phone; 5-0 Cell *a ax # (E mail tYl d t I
:APPLICANT INFORMATION
Check any that apply: j Change of ow_ \ner�ship Cp ha %nge 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 parkingspaces, number of
vehicles, and any additional information that you can provider
*This Clearance will only be valid on.the parcel for which it is approved. Ifyou change, intensify or move the use to a new Iocaton, a new Zoning
Clearance will be required.
I hereby certify that 1. 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 acccuur% to the best of my luiowledgo. conditions of approval; and I understand them, and that I will abide by them.
Signature / Printed
APPROVAL INFO ATION
tApproved as prop ed [ 1 Approved with conditions [ ] Denied
[ ] Backflow prevention device and /or current test data needed for this site. Contact ACSA, 977451 I, 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 C Date_
1 [
Zoning Official Date
Other Official Date
_ -3
Lounty of Albemarle (Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -41126
Revised 7/1/2011 Page 2 of 3
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Intake to complete the following:
Y/O
Is use in LI, HI or PDIP zoning?
Engineer's Report (CER) packet.
If so, give applicant a Certified
Y /
Wil 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 appl'
Is parcel on private w 11 or.publ� ater?
If private well, provide De artment 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;; c sewer.
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 #
Znninu to eomnlete the following:
Reviewer to complete the following:
Square footage of Use: 13 66
iitted as: T'Fi c..,.; lily
Under Section: `-Jl ;�j .2.1
Supplementary regulations section:
Parking formula:
Required spaces:
Y/N
Items to be verified in the field:
Inspector:
Notes:
Date:
Violations:
Y /L9
If so, List:
Proff rs:
Y / N(
If so, List:
Variance:
If sogist:
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,
[County application name and number]
was provided the owner of record of Tax Map rnM [name(s) of the record owners of1the parcel]
and Parcel Number 0 (o 'jvj I t) — 0 — (q
0 jQD,�E Q 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 :Joel - Sck P-C47na I
[Name 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 H to the followi ng,adch-ess:
--bate
[address; writiennotice mailed at die 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].
Signature of A 5 . cant
Print j1,ppli ant Name
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