HomeMy WebLinkAboutCLE201300226 Legacy Document 2013-10-04Application for Zolin ' Clearance
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OFFICE USE ONLY -�
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PLEASE REVIEW ALL 3 SHEETS
Check # Date:
Receipt # Staff:
PARCEL INFORMATION ,
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Tax Map and Parcel: Existing Zoning
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Parcel Owner: A-e-N�`� <s- �1 �r /1- e -e4&9�
Parcel Address: eS G�* \Gy te Zip
include 1 of floor) >
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PRIMARY CONTACT
Who should we call /write concerning this project? e- i-S C, Yl
Address :,a W Gc-G1. LjL,c,J( Citye.a � 6otY2ts C, icState (% iti Zips p
Office Phone: G Cell # Fax # E -mail dde c'l-i c Yh cs�rlt`iCc
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name --'New business
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Business Name /Type: (� eyl e< YK e ri— CA, s S•<4- 010 n AtSe- 01 e 4+ , r` L C
Previous Business on this site
Describe the proposed business including use, number of employees, number of shifts, availabl parking space s, number of
vehicles, and any additional information that you can provide:, /.-"f ��f'�! ej1 f /� G Ise'i- 4 /� (JS/ e 57
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fi Z C, d S
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*This Clearance w 4 my be valid on the pare' for Uiich it is approved. If you change, intensify or move the use to a rreiv location, a new Zoning
Clearance will be required.
I hereby certify th , 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 accu to th est o my kno edge. I 1 ave read the conditions of approval, andg I understand them, and that I will abide by them.
Signature Printed �cLC'_.�� Cie
APPROVAL 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 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
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Intake to complete the following:
Y lQ
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y
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 a Y
If private well, provide 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 septic o ublic sewer?
Y /
Wil 19you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y /<
Will t ere be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to comDlete the following:
Reviewer to complete the following:
Square footage of Use: (Oz?
I/N
Permitted as: 6
Under Section:
Supplementary regulations section:
Parking formula :�"
Required spaces:
Y /
Items to be verified in the field:
Inspector: Date:
Notes:
Violat'ons:
Y /6I
If so, List:
Proffers:
Y/N
If so, List:
Variance:
O/N
If so, List:
7-00o- 13
SP's:
Y /QJ
If so, List:
9
,�9
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.
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I certify that notice of the application, _ ' Gt
[County application name and number]
was provided to W)o Cv 2 the owner of record of Tax Map V
namthe re cord o ners of th _, ;ce —]]-
and Parcel Number C-" ! by delivering a copy of the application in the
manner identified below: Sc> ; le C. .A -)L ;2 j C%f
cN, CX-6 + es LP 1
Hand delivering a copy of the application to �the- �`d
*ame ord owner if the recW 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 /,q-o-
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].
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Signature of Applicant
Print Applicant Name
;2 _
Date