HomeMy WebLinkAboutCLE201300105 Legacy Document 2013-05-31Application for Zoning Clearance
117
CLE # Gb I-I
PLEASE RE' ALL 3 SHEETS
orFlcE s t ��
Cheelc# Date:
Receipt # Staff :�/
PARCEL INFORMATION c� I
Tax Map and Parcel: -1 0 1 t M Existing Zoning p0mc
Parcel Owner: U V N (ZE N L tti STAT T::o V N P Al o N
trL P- Jl- cit 7,291
Parcel Address: �� N�(� -� � 1 yC. li•y�1�1.,�- State y � Zip
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project? AVE 1N
Address: L400 VJ n(La-C(j-- pouvU- city,CWVILUl State VA Zip 7,2,911
Office Phone: 3' 244- 02-.3yCeI1 �ySLFax #2jq+0235, E -mail j.6M3D e yta4twa.e
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name /Type: KLV �C---" Ac 13b 2161 ti!AL ft-V- Z "JE bti1 a 1" y' VA
Previous Business on this site VV y 12V1,C--LL
Describe the proposed business including use, number of employees, number of shifts, available parking space n ber of
vehicles, and any additional information that you can provide: (S tNe ✓r al" d
Za sr is s Se Wv UL 119
,u tl - 3UU-i 117S, 1 fiu
*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 accurat to the best of my o edge, I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature Printed
I L11
APPROVAL INFORMATION
] Approved as proposed [ ] Approved with conditions j ] 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. • I
[ ] This site complies with the site plan as of this date.
Notes:
`�— Date
Building Official
Zoning Official Date
Other Official Date
J_ounLy 01 RjL)C 11i11-1r .UCINal-uuuul U-1 VV11114[U111L,T a.rc.—AVj.---..-
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126 }
Revised 7/1/2011 Page 2 of
o d
i�-
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 l _
Wil ere be food preparation?
Reviewer to complete the following:
Square footage of Use:
0/ N.
Permitted as: 4 ,L'_CeS��rY
Under Section:
If so, give applicant a Health Department'form.
Zoning review can not begin until we receive approval from Health
Supplementary regulations section:
Dept. FAX DATE
Circle the one that applies
Is parcel on private well o ublic wnte ,
If private well, provide Health Department form.
Zoning review can not begin until we. receive approval from Health
Parking formula:
Required spaces:
Dept. FAX DATE
SP's•
f ' �
i f so, :st:
Y/N
Circle the one t t applies
Items to be verified in the field:
Is parcel o eptic r public sewer?
Y _
Wi u be putting up a new sign of any kind? If so, obtain proper
—
SDP's
Sign permit.
Permit #
Inspector : Date:
Y
Notes:
Wi be any new construction or renovations?
Oere
If so, obtain the proper Permit.
Permit #
uwiut w —...
Violations:
Y //
If S/O ist:
Proffers:
C) /N
If so, List:
Varm e:
Y / �
If so, t:
SP's•
f ' �
i f so, :st:
Clearances:
SDP's
Revised 7/1/2011 Page 3 of
E
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, Zo vH�`61 � L yi QQI
[CouAty application name and number]
was provided to Q �rccordo v V �. the owner of record of Tax Map
[name s) of ths of the parcel]
and Parcel Number _ X I M 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]
low
Date .
Mailing a copy of the application to 'V� y •J A '�T, VUK& ^ 1 D n
[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 �k W,4 to the following address:
Date ,JJ
P god y�uZl�, ayie, g otiYs Ika�- y0\14e G�a�•(ic�v+l�.
[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].
Si&dure of Applicant
Print Applicant Name
Date
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