HomeMy WebLinkAboutCLE201300199 Legacy Document 2013-09-13f �
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Applicati ®n f ®r Zoning Clearance v�
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PLEASE REVIEW ALL 3 SHEETS
OFFICE US �11
Check # �.;7 Date:
Receipt # q 24110 Staff:
PARCEL INFORMATION
Tax Map and Parcel: r a S Existing Zoning o
Parcel Owner: K055ek '4S- 5- d14T'ef L L c-
Parcel Address: -- .2 ya k .Z yv Rd- City C4412 lerreSvi A/ State I,// R „vi , zip
(include suite or floor)
PRIMARY CONTACT •-�
Who should we call /write concerning this project? off, �eol+ e2 1%i c r
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SPa,g y CAN e .Zn.vesra,ftiT C6W
Address : n. City r1a2ll17ef , �� State // i �� ywi4 _ Zip ddyud
Office Phone: ( �t�) 95 i y� iy Cell # c/3Y,5 -31 /070 Fax # 4 /3 `/ ce/ % /yl _mail -cOm p om ee-A g016OP -7
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name /Type: -SRS, IAn�P �%vUPJirhPtiT ��/� �jo %l,N Ce.H A
Previous Business on this site 11V//9 "
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: � Pkjy e-es / .S�1 r7
S�aCPf .S�ia4Ed tv,r( OT.fl? OCCyeA,v71 pF e, 1
*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 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 accurate to", st of my I have read the conditions of approval, and I understand them, and that I will abide by them.
jknowledge.
G' `R� \ SP'?' I� L�•.✓f �N vPJTT�t/
Signature l% 1°
Printed
APPROVAL INFORMATION
t>c],'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 �— Dated
Zoning Official l Date )z
Other Official Date
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:
Reviewer to complete the following:
Y /`. / Square footage of Use: �b Gy
Is use m LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet. J� / N
Permitted as:
Z' /O_ - -
Will there be food preparation? Under Section: v j
If so, give applicant a Health Department form.
Zoning review can not begin until we receive approval from Health Supplementary regulations section:
Dept. FAX DATE
Circle the one that applies
Is parcel on private well or
If private well, provide Hea partment form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applies
Is parcel on septic r public sewer?
Y /(PWill ou be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y /O
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the following:
Parking formula:
Z",
Required spaces:
Y/N
Items to be verified in the field:
Inspector :
Notes:
Date:
Violations:
Y / t3q)
If so, ist:
Proffers.
Y /('N
If so, ist:
Variance:
Y /,Y�I
If s o st:
SP's:
OIN
If so, List:
�)7r 7
J
Clearances:
SDP's
1-7-34-/
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 (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,
was provided to
[County application name and number]
poSse2 AS OcigTel L'�G
[name(s) of the record owners of the parcel]
and Parcel Number bo r
manner ide.:itified below:
J� %31 . Po leacq /?'►�3W&y l
/ Hand delivering a copy of the application to _ o�JeR- . =3'sa e iAT�s
[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]
the owner of record of Tax Map
by delivering a copy of the application in the
on 0.20 -- oo
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].
Signature of Applicant
7zorn,9s #- ��""��j vl�-r pr,s, dQ„i
Print Applicant Name
&-20 -2013
Date
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