HomeMy WebLinkAboutCLE201300123 Legacy Document 2013-06-11Application for Zoning Clearance
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CLE # 201 123
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OFFICE USE
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PLEASE REVIEW ALL 3 SHEETS
Check # Date:
Receipt # C Staff:
PARCEL INFORMATION yy �j I
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Tax Map and Parcel: L9 ( - I Existing Zoning
Parcel Owner: M(Ayl U m�u.%1 I b .C_n �CA Vcty , Rail
Parcel Address: WO CA VlU 1— City Cf1 Wkl+ b Al C State V P Zip aau oc
(include suite or floor)
PRIMARY CONTACT ,,��
Who should we call /write concerning this project? VIVCj kM Q 1jl 'eV1kAI NWhtAIM
Address : �J(SS uyr fzjrm P City U(JV(I) SjjA1e State U Zip aq
Office Phone: ( ) A,cl(p-15C(9 Cell # 631�U'P� Fax # aqU 7 `I(( E -mail Iq Fb +,�Ct'�(°yli r � I CDin
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name /Type: c � ` X/-,) I-, n/ 4VV(0 3 h C4 I— --
Previous Business on this site
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:
*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 accu ate to the be of k ledge. I have read the conditions of approval, and I them, and that I will abide by them.
understand
Printed
Signature
PPROVAL 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 C' P 1
/I
Date
Zoning Official
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:
Y/-
Is u�e/ifi. LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y / �re Will 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
Reviewer to complete the following:
Square footage of Use:
)/ N
Permitted as: �e.d►��' �"i` "
Under Section: M. � I
Supplementary regulations section:
Circle the one that applies Parking formula:
Is parcel on private well ,°r pub�artmcntfbrm. r?
If private well, provide HbaRh-D
Zoning review can not begin until we receive approval from Health Required spaces:
Dept. FAX DATE
Circle the one that apCubli Is parcel on septic or
�ill /N
you be putting up a new sign of any kind?
Sign permit. i ' �
Permit # i Q
Y/
Item 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 pr per Permit.
Permit # a U f
Zoning to comnlete the followine:
Viol tions:
Y /
If so, ist.
Proffers:
Y rN-)
If sv st:
Vari ti'e:
Y,O
If so, ist:
SP's:
Y /N(�
If so, ist:
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 record owners of the parcel]
and Parcel Number
manner identified below:
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
[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].
Sigilature of Applicant
Print Applicant Name
Date
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