HomeMy WebLinkAboutCLE201300142 Legacy Document 2013-07-08• • •
Application for Zoning Clearance
CLE # Q013 — � 'I
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PLEASE REVIEW ALL 3 SHEETS
OFFICE USE ONLY
Check # O 617 Date: E") —i3
Receipt # Staff: '-
PARCEL INFORMATION L
Tax Map and Parcel: ocl oco—W — 00 r 03517 o Existing Zoning
R D R D LA_
Parcel Owner: i
Parcel Address: 1004 Jnow Po I rr c U4 City 1, V I �� State VA ZiPUN
(include suite or floor)
PRIMARY CONTACT IV
I lAb d
Who should we call /write concerning this project? i UJa(
Address; �1 ��� G , ua XI ( Ci C U State V Zip
.
ll# Z /�I C) W g R
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Office Phone: L� C Fax # E -mail �fJ (ll
3
APPLICANT INFORMATION
Check any that apply: of ownership Change of use of name New business
�iChange
`��Changje
I
Business Name/Type: 1 �� 1'�c IJw ^'S
Previous Business on this site
Describe the proposed business including use, number of employees, nu ber of shifts, availabl parking spaces, u ber of
a scale, m o c C ctS5
vehi les, a d any additional information that you can provide: n ICI
S er (as 1'lY),VC -M S" A�C a v Ale 1" @ 7-
�ul2kcln S aces � Al ee s ' 2 U fh I � s
This Clehrance will onfy be valid on the part 1 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 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 act rat o th e best of m lrno ledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature IWAIIIAW 14&WO CY Printed 1/t �� �ffi q M I l
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 —I 3
Zoning Official Date ;7
Other Official �V t ~ �— Date J j�
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:
UN
se i LI HI or PDIP zoning? If so, give applicant a Certified
Engineer eport (CER) packet.
Y /
Will re 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 applies
Is parcel on private well o ublic water?
If private well, provide Heal ent form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that appli
Is parcel on septic o ublic sewer?
Y /
Wila be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y /
Will thde be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the following:
Reviewer to complete the following:
Square footage of Use: /t; �71 ()
0/ N
Permitted as: _ 46AA Nc r� ic!�Y
Under Section: .)- 6'. Z. I
Supplementary regulations section:
Parking formula:
k /z' T
Required spaces: �1
Y/ <<
Items to be verified in the field:
Inspector • Date:
Notes:
Violations:
Y/N
If so, List:
Proffers:
Y/N
If so, List:
Variance:
Y/N
If so, List:
SP's:
Y/N
If so, List:
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3
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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, ZG AI I t%'1 C- l e A 2 >4 N C -v--
/ [County a placation name and number]
was provided to ` PI) L L C- the owner of record of Tax Map
[name(s) of the/record owners of the parcel]
and Parcel Number O q 6 6 - 06 ` 06 ° � � �� b by delivering a copy of the application in the
manne r identified below:
V / Hand delivering a copy of the application to go No L L
[Name of the rec rd 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 1 Z _ 9 6
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].
Signatyre of Applicant
W11la1n wi 06W 14 i2 CL
Print Applicant Name
Date