HomeMy WebLinkAboutCLE201300180 Legacy Document 2013-08-08Application for Zoning Clearance
CLE # -
�,1 ���a��� °�
OFFICE
PLEASE REVIEW ALL 3 SHEETS
%0N
Check # Date:
Receipt # Staff:
PARCEL INFORMATION
Tax Map and Parcel: 0? oo ® 10 `° P t, — ® A Existing Zoning
Parcel Owner: 3 K Rol lt-E Vl e"'D(j Prog d -u-s
Parcel Address: Eo7 k-fn QoAj City NX-rWo Ull12_ State Zip r`t
(include suite or floor)
PRIMARY CONTACT } Novad Who should we call /write concerning this project? 0 i'1�Yf Ac l !A* V f I no RIM
Address: ��u Cup' - Ili' �� }1�,�tGt��- F1,��{,1L1(LVctLity ��L��'� State ktC'
Office Phone: I(�3C17 �V >Ub Cell # Fax # "t l0 �3cls t -mail Ct`7( rwt .111( iniOUX --4 r ,
APPLICANT INFO TION
Check any that apply: Change of ownership Change of use Change of came New business
BusirressiYame/Type; QcC ,I �011VQ.jl1Cj'lCP S Y�
Previous Business on this site Ih) -,d
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 urill only be valid on the parcel for which it is approved. If you change, intensify or move the use tort new location, anew Zoning
Clearance will be required.
I hereby certify that I wiz or have the oivners permission to use the space indicated on this application. I also certify that the information provided
is true and accurate t the best of my knowledge. I have read the conditions of approval, and I`unders`tand them, and thatI will abide by them.
Signature Printed
APPROVAL INFORMATION
Approved as proposed [ ] Approved with conditions [ ] Denied
[ ] Backflow prevention device and /or earrent test data needed for this site. Contact ACSA, 977 -4511, x117.
[ ] NTo physical site inspection has been done for this clearance. Therefore, it is not a determination of compliance with ilia existing
site plan.
[ ] This site complies with the site plan as of this date.
Notes:
Building Official Date
Zoning Official MA-0- Date
Other Official Date
---C�ty of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
Revised 711/2011 Page 2 of 3
5'.
k)l
Intake to complete the following:
Y/
Is a LI, M or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CPR) packet.
; / N
III 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
Circle the one that applies
Is parcel on private well , 1-'public i ater?
If private well, provide IIe rtment form.
Zoning review can not begin until we receive approval front Health
Dept. FAX DATE
Circle the one that apIs parcel on sep tic o?
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y/N
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Pemilt ff
Zoning to complete the following:
Reviewer to complete the following:
Square footage of Use:
(I,)/ N 1
Permitted as : —. R of
Under Section:. I— 4'A ,2
Supplementary regulations section:
Parking formula:
Required spaces:
Y/i
Items o be verified in the field:
Inspector : Date:
Notes:
Violations:
If
If so L' t:
Proffers:
/ N
Q so, List:
Val
I fs R'llee:
t st:
Y /�if
if so, ���tst:
Clearances:
SDP's
Revised 711/2011 Page 3 of 3
e
CERTIFICATION THAT NOTICE OF THE
APPLICATION HAS BEEN PROVIDED TO THE LANDOWNER
This form must accompany zoning applications (Borne Occupation, Zoning Clearance, Zoning
Administrator Determinations orAppeals, Sign Permits, Building Permits) if the application is not the
owner.
I certify that notice of the application, Ohiuu/�' C6 q -t�l 10 at/1:6
[County application name and number]
teas provided to `� �, k the owner of record of Tax Map
[name(s) of the record owners o the parcel]
and Parcel Number 07R DO ' bb ' Ob 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]
on
Date
Zmalling 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 e�>/Of )3 to the following address;
Date
[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
Mkt. k Okla
Print Applicant Name
Date