HomeMy WebLinkAboutCLE201300179 Legacy Document 2013-08-08Application for Zoning Clearance
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PLEASE REVIEW ALL 3 SHEETS
Cllecic # oZ Date:
Receipt # Staff:
PARCEL INFORMATION
Tax Map and Parcel: 7 oo —'0 0 a 00- Poo Existillg zolllllg rpm �
Parcel Owner:
Parcel Address:_ NO -Qdk(n e0kri City Cj,! l4k5ut -t gState V4 Zil�
(include suite or floor)
PRIMARY CONTACT
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Wilo no Td d
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should we call concerning this project? -vilA V
Address: lL� {� `oi�`��� �U nUUCI,t u T�t ���,LLti �lVcCity_ f V L��� State Zi
Office Phone: I( )0 A5 �7)a Cell# Fax #If00 3`"G 60 h -nail 11,� U1
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APPLICANT INF OBMATION
Change of ownership Change of use Change of nave New business
Check any that apply:I '
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Business NalnefIype: �2,eh6
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Previous Business on this site ICJQ 6LLI (.()JAVII/tAULCil
Describe the proposed business including use, number of employees, number of shifts, available parldng spaces, number of
vehicles, and ally additioIlal inforIIlation that you. call pI'ovide:
*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 l�4'Il or have the owner's permission to use the space indicated on this application. I also certify that the information provided
is tnuo and accurate t the best of my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them,
Signature Printed /�ry- KUkW -' 6
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:
Btlilding Official ( Date
Zoning Official Date �`7A y/ 3
Other Official Date
Coigi$y of Albemarle Department of Community Development
401 Mchitire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
Revised 7/1/2011 Page 2 of 3
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Intake to complete the following:
Y / (�)
Is use in LI, HI or PDIP zoning?
Engineer's Report (CER) packet.
If so, give applicant a Certified
V ill N
there 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:
Under Section: 'Z-5 4. -Z. I
Supplementary regulations section:
Circle the one that applies Parking formula;
Is parcel on private well or A] Ater? � �^ y
If private well, provide Hea rtnient fond.
Zoning review can not begin until we receive approval fiom Health Required spaces:
Dept. FAX DATE
Y/N
Circle the one that applies Items to be verified in the field:
Is parcel on septic ` u rc s ?
Y/N
Will you be putting up a new sign of an), kind? If so, obtain proper
Sign permit.
Per►nit # Inspector: Date:
Y/N
Will there be any new constnrction or renovations?
If so, obtain the proper Pennit.
Permit #
Zoning to complete the following:
Notes:
Viola 'ons:
Y/'
If so, List:
Proffers:
fY IN
If so, List:
varla ice:
Y /(
If so, rst:
/ N
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 {Horace Occupation, Zoning Clearance, Zoning
A(lininistrator Determinations or Appeals, Sign Permits, Building Perinits) if the application is not the
WWI,.
I certify that notice of the application, 6 1 Lx )n i')� Cu-vwh _, D}'1,t.e4
�} (� [County application naive and iumber]
was provided to 9N) 1` Cl V't n I' i' 001y i � the owner of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number �l 3lJD . l7 6—/) . (" I (t)O0 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]
Oil
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, identit, the recipient of the record and the recipient's title or
office for that entity]
Oil
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].
Signature of Applicant
(6 It
Print Applicant Name
q)�VI�-)�
Date