HomeMy WebLinkAboutCLE201300182 Legacy Document 2013-08-08Applicati ®n for Zoning Clearance
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OFFICE O Y
PLEASE REVIEW ALL 3 SHEETS
Check Date.: - °-
Receipt # Staff:
PARCEL INFORMATION
Tax Map and Parcel: n a o®— p ®— - 0 376?2xxisting Zoning
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Parcel Owner:
Parcel Address. cep-, iM1e- _F( ri City CPAJOiTFS he State V l�
(include suite or floor)
PRIMARY CONTACT
Who should we call /write concerning this project?
Address'. MAD ��}'}i�1'� U t1yU1 � �.� �1 � {.i 11(�LVG(;ity �� State 1U C' Zir% ! �
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OfficePlione: � -2)Ub Cell# Fax# fjQ������tE C� ?c�.rr��L,f1���fn1�I1Vs)�a
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APPLICANT INF ORMATION
Check any that apply: Change of ownership Change of use Change of name New business
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Business Nante/Type:
Previous Business on this site I &Aa i _.()JAWlJl.le6`U S+61(
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 anew location, a new Zoning
Clearance will be required,
I hereby certify that I o i or have the owner's permission to use the space indicated on this application. I also certify that the information provided
is true and accurate to ie best of my knowledge, I have read the conditions of approval, and I understand them, and that I will abide by them,
Signature Printed �i ko� V11, W
APPROVAL INFORMATION
Approved as proposed [ ] Approved with conditions [ ] Denied
[ ] Baekflow 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 1 Date
Zoning Official _ Date %�� 6.)3
Other Official Date
County of Albemarle Department of Community Development
441 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
Revised 7/1/2011 Page 2 of 3
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I Intake to complete the following: I Reviewer to complete the following:
Y /6P Square footage of Use:
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet, Y / N
Permitted as:
/N
� ill there be food preparation? Under Section:
If so, give applicant a Health Department form,
Zoning review can not begin until Nye receive approval firom Health Supplementary regulations section:
Dept, FAX DATE
Circle the one that applies
Is parcel on private well or li vater?
Parking formula:
If private well, provide Hex tment form,
Zoning review can not begin until the receive approval from Health
Required spaces:
Dept, FAX DATE
Y/N
Circle the one that applies
Items to be verified in the field:
Is parcel on septic or re!�er?
YIN
Will you be putting hip a new sign of any kind? If so, obtain proper
Sign permit,
Permit
Inspector: Date:
Y / N
Notes:
Will there be any new construction or renovations?
If so, obtain the proper Permit,
Permit #
ZotiinLy to calnDiete the following:
Viola 'ons:
Y/ Itr
If so, List:
Proffers:
Y/N
If so, List:
Variance:
Y/0
If so, List:
Y/
If so, List:
Clearances:
SDP's a�
Revised 7/1/2011 Page 3 of 3
CERTIFICATI ®N THAT NOTICE OF THE
APPLICATION RAS ]BEEN PROVIDED TO THE LANDOWNER
This form must accompany zoning applications (Horne Occupation, Zonhig Clearance, Zoning
Administrator Determinations or Appeals, Sign Permits, Building Perfnks) if the application is not the
owner.
1 certify that notice of the application, M01,111avie
[County application name and number]
was rovided to I �� i vyrii i-he p the owner of record of Tax Map
[nane(s) of the record owners of the parcel]
and Parcel Number 03Z- --6() -- (T) yW Q?; %Z 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
[Nance 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
officesfoJr/th/at entity]
on �'1 {�'f },� 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 Naive
1
Date
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