HomeMy WebLinkAboutCLE201300218 Legacy Document 2013-09-16U MAI),
Application fon r Zoning Clearance
C y1
PLEASE REVIEW ALL 3 SHEETS
OFFICE t1� 119 Y
Check # iC1DCJ Date:
Receipt # X93 g2'N43 Staff: nUT .
PARCEL INFORMATION
Pa.reel 17-76 rt,- ()T-rice,
Tax Map and Parcel: MQ I Existing Zoning 1Mme(wk
Parcel Owner: Vn n � C r Linde (ices c-•
/Ztq
Parcel Address:lyy5 Ric, Road &aSf� SI�) r' city UIC11'la N1IleState VA Zip 22,7W
u��a tl Q ` (iin`lclu e,suit or floor) C2 n J F' ►oor'
PRIMARY CONTACT -� ,
Who should we call /write concerning this project? a sslcoL.
',-51q5 (-; kke. Df. of l" *M( I IreState V k 22q
Address: GY)V1 City l> Zip
,r l' _ t .
Office Phone: (_�N n Cell #C�I3�►) q60 Fax # je.S $ l C�i.eure@ q YYicli �.
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
'_X
Business Name /Type: 1 a —eu d ba CSC m m4 t I m Q.
(, �; }t QraCfice PsycMo�kerapy
Previous Business on this site txYi KV%ow n
Describe the proposed business including use, number of employees, number of shifts, acv- ailabI parking spaces, number of
i l
vehicles, and any additional information that you can provide: 6 �e C5�1•t nM
em P—; , tte d aO 1u,3
r n ce .
his Clearapke 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 the best of my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature Gam. L �e.. Printed 'SS i C- L M • F. - rl,
APPROUL 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
Building Official Date
Zoning Official ' 7k%�-D Date
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
corn
Intake to complete the following:
Y /b
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y / T"
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 - •�2
Is parcel on private well or purl c w ter.
If private well, provide Healthfepartment form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applies
Is parcel on septic or<tublic sewer?
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.
Permit #
Zoning to complete the following:
Reviewer to complete the following:
Square footage of Use: f d J c7
Y/N
Permitted as:
Under Section:
Supplementary regulations section:
Parking formula:
Required spaces:
Y/N
Items to be verified in the field:
Inspector : Date:
Notes:
Violations:
Y/N
If so, List:
Proffers:
Y/N
If so, List:
Variance:
Y/N
If so, List:
SP's:
Y/N
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 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,
(01UMCL
was provided to Van der l.l' ae, T IU rn es , 10C • the owner of record of Tax Map
[name(s) of the record owners of the parcel]
T
and Parcel Number Mn.P L i PafCf ( J Z i 5 by delivering a copy of the application in the
manner identified below:
Hand delivering a copy of the application to vale kc l (lde t-6(ne s, Tema- Led �Pb rd ;p
[Name of the record owner if the record owner is a 0-AR C,e,
person; if the owner of record is an entity, identify the recipient of the record and the recipient's NCO IT Y,
title or office for that entity] Q
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].
..
re of Applicant �(
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