HomeMy WebLinkAboutCLE201300181 Legacy Document 2013-08-08-� �o!st)re
Application for Zoning Clearance
CLE # 1 -191
PLEASE RE' ALL 3 SHE, ETS
OFFIC t '0 Y
Clrecic #' Date:
Receipt ' Staff:
PARCEL INFORMATION r
Tax Map and Parrccel: —® - '0®- a `4 ®0r Existing Zoning 7) 0)
Parcel Owner: tJ�1'i. Ii�j'j l - i'��%�Cl1.J'1t� O�
Parcel Address: ICILI Avenue City '/oze 4- State U ZfpO�)'
(include suite or floor)
PRIMARY CONTACT / `n r
\Vlio /Nvrite Ct �' ayllAt. + 4���V I h4�� Noma( l T z d
sl►ould we call concerning this project?
Address: ���((� (��'1't�'1�UhV� tat 11�9�.�1l��mity t I fill State W,
Office Phone: IU M,5 �� >� Cell 9 Fax A (a �3q-(;& Lrnail t�� �G�YI?i� •�����fJll'li � +r��J�
.APPLICANT INFO TION
Check any that apply: Change of ownership Change of use Change of name New business
Re (wAVt) --w)1U Si�Y
BusinessName/Type: _ a'd
Previous Business on this site_ I &ta(.I (.tiNAyn/LLeGQ0 S �I(
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 requ' ed.
I Hereby certify that wn or have the owner's permission to use the space indicated on this application. I also certify that the infonnation provided
is true and accurate the best of my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature A,jt LUT 16r
Printed I�CJt/
APPROVAL INFORMATION
><j 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
Zoning Official Date1 bl3
Other Official Date
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5532 Fax: (434) 972 -4126
Revised 7/1/2011 Page 2 of 3
x'11
Intake to complete the following:
Y 4l
Is use li; LI, M or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
/V /N
Will 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 or(C' abbe �v. er?
If private well, provide HeaWt- Department form.
Zoning review can not begin until we receive approval from Health
Dept. PAX DATE
Circle the one that appli
Is parcel on septic or itc serve
Y/N
Will you be putting tip a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
y /Nr
Will there be arty new construction or renovations?
If so, obtain the proper Pennit.
Permit #
Zoninfy to cmmTlPtP flip fnllncum".
Reviewer to complete the following:
Square footage of Use:
Y/N
ermitted as:
Under Section: lb • �'
Supplementary regulations section:
Parking formula:
Inspector-
Notes:
Date:
Violations:
If so, List:
PiDUS:
f so, List:
V riance:
/N
If so, List:
SP's:
Y/V
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 (tccoinp. any Zoning al)plications (Home Occupation, Zoning Clearance, Zoning
AdntinisttatorDeterminations orAppe(rls, Sign Permits, Building Permits) if the application is not file
WWII.
I certify that notice of the application, (4112 E`oar t e 661 oh j Zor1,ul o
i?ze"v0C1d41 [Co unty application name and ttum er]
tivas provided to SQ, l f �1 t I r u sr the owner of record of Tax Map
[nam s} 9the record owners of the parcel]
and Parcel Number N &A C 12-q 6� 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
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 9-D 0 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
Print Applicant Name
cvjjI)�
Date