HomeMy WebLinkAboutCLE201300114 Legacy Document 2013-05-31Application for Zoning Clearance�r,l.,,�.
CLE # 20 `'b - 1 1 �-
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PLEASE REVIEW ALL 3 SHEETS
OFFICE USE ONLY
Check# ICD Date:
# Staff:
Receipt
PARCEL INFORMATION
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( IN 1 -2r ` Existing Zoning �JI ` � t)
Tax Map and Parcel: �P 1 I
Parcel Owner: i'�L Z��, A - (-- �
�� s¢'cG Ji City Ciro irktdC OA State zip T901
Parcel Address: u4/1 ti -�^
(include suite or floor)
PRIMARY CONTACT
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Who should we call /write concerning h�pro
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Address city V-\�kdC�l AC State Zipu 9v V
Office Phone:'�� ?3 J%j OCell #`G�3�' Y # E -mail C�tj C_`�'P, (. `"0
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APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
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Business Name /Type:-- -��� -��rS
Previous Business on this site
Describe the proposed business including use, number of employees, ,Wnber of shifts, available parking spaces, number of
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vehicles and any additional information that you can provide:
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*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 havpkkn er's permission to use the space indicated on this application. I also certify that the information provided
is true and e h f led I have read the conditions of appro , I understand them that I will abide by them.
UPes
Si nature��n .�� Printed O N .ns
Signature
INFORMATION
as proposed [ ] Approved with conditions [ ] Denied
]Approved
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 (�%((A
Zoning Official Date
Other Official 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
Intake to complete the following:
Reviewer to complete the following:
y Square footage of Use:
Is u OLI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet. VIN
Permitted as: �✓ t^� n
Y/
Will ere be food preparation? Under Section: .7-1Z Z•
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 public water?
If private well, provide Hea 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 o pub is sewer?
Y N
Wi ou be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Perm'
Y/N
Wi I t e be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
7nninv to emmnlete the following:
Parking formula:
Required spaces:
Y/
Items to be verified in the field:
Inspector:
Notes:
Date:
Violations:
If so., list:
Proffers:
If so,'i`ist:
Variance:
Y /((1Gll
If so`- st:
SP's:
Y/1
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,
was provided to
[County application name and number]
[name(s) of the record owners of the parcel]
and Parcel Number
manner identified below:
the owner of record of Tax Map
by delivering a copy of the application in the
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 9L.v. tiic ^ L a S
[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].
Si nature of Applicant
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Print App icant Name
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Date
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