HomeMy WebLinkAboutCLE201300225 Legacy Document 2013-09-23• • •
Application for Zoning Clearance
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CLE # ��� -2.25
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PLEASE REVIEW ALL 3 SHEETS
OFFICE USE ONLY �� (-'2
Check # % Date: I
Receipt # Staff:
PARCEL INFORMATION�� �y On �y
t "I L Existing Zoning IJ
Tax Map and Parcel:
Parcel Owner: elrii 0. r
Parcel Address: W OoA rn"u. C City CkorJp4JgmJ6 State Uk Zip 22 Y (7
(include suite or floor)
PRIMARY CONTACT
(14r le-1 Gm-. SO
Who should we call /write concerning this project?
Address: 41oS Ron::y CU've� City [oAlCy c State v� Zip
Office Phone: 4 U 22 Cell # &4� Fax # ``I!!a E -mail 1:11- r 0-14-1A r ryes n C� e e q Le 'l �-
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
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Business Name /Type: Ckw-6 Ae'6(
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Previous Business on this site
Describe the proposed business including use, number of employees, number of shifts availabi 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 required.
I hereby certi 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 ac u to to the best of my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
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Printed
eRMATION
FORMATION
posed [ ] Approved with conditions [ ] Denied
ntion device and /or current test data needed for this site. Contact ACSA, 977 -4511, x117.
with the existing
inspection has been done for this clearance. Therefore, it is not a determination of compliance
site plan.
[ ] This site complies with the site plan as of this date.
Notes:
Building Official Date ri
2
Zoning Official Date 3
Other Official Date
County 01 Albemarle Lepartmemt lm k- ut[mnuiiity licvwvNi.cia�
401 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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Intake to complete the following:
Y/N
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y /
Wi ere 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 o ublie water?
If private well, provide Heat epartment form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applies
Is parcel on septic o public sewer?
Y
Wi ou be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
YO
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
17 „rt 4•n nmmnlnffn Ap fnlinwina-
Reviewer to complete the following:
Square footage of Use: "''1 6n
/ N itted as:
erm
Under Section: I
Supplementary regulations section:
Parking formula: �U V
Required spaces:
Y/N a
Items to be verified in the field:
Inspector : Z Date:
Notes:
LJ V 11111 L V
Viol tions:
If s `Li st:
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
V r
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]
[name(s) of the record owners of the parcel]
and Parcel Number
manner identified below:
the owner of record of Tax Map
by delivering a copy of the application in the
Hand delivering a copy of the application to Q 4 1 e Poo -rTI
[Name of the rec rd 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 T lo • i
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 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].
4Si nature of Applicant
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Print Applicant Name
ate
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