HomeMy WebLinkAboutCLE201300135 Legacy Document 2013-10-17Application for Zoning Clearance
CLE # 135
PLEASE REVIEW ALL 3 SHEETS
OFFICE U 5 ON r�
Check #�1 OI Date:
I Staff:
Receipt # = ot ob
PARCEL INFORMATION
Tax Map and Parcel: (b Q ^ t' ' id S ", Existing Zoning
Parcel Owner: ��, `O�
D� ty e�.s Zip
Parcel Address:
;. (inclV! suite or �r)
PRIMARY CONTACT
Who should we call /write concernipg, t his project?
slK V-ty
Address: \ 1 State V V `► Z`ip,� \
Office Phone: `r II # Fax # E -mail
APPLICANT INFORMATION
Check any that apply: Change of owners kip Change of use Change of name L- New business
Business Name /Type: �
C'
Previous Business on this site
Describe the proposed business including use, number of employ es, number of shifts, avai ble p. rking spaces, number o
vehicles, and any additional information that you can provide: �� � � � _ ` "�� 'L
�
1 D, y1 S
*This Clearance wiMQn be valid on the arcel for which is appr ved. If you change, intensify or move the use to a new location, anew oning
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 ap roval, and I understand the , nd �Iwi 1 ab'.de b t m.
Si nature Printed \ �- -'
Signature ��
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 witli 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
V�
Intake to complete the following:
Y /( )
Is use m LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y 1`tl'i
Wil 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 public water.
If private well, provide He nent 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 u lic sewer?
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit
Permit #
WY it N
ill there be any new construction or renovations?
If so, obtai%the ppgper Permit.
Permit I 1 00
7nnina to vmmnlete the following:
Reviewer to complete the following:
Square footage of Use: aA f
)Y /N ryry��-j
lrermitted as: fQ%4�M 1 1
Under Section:_•`
Supplementary regulations section:
Parking formula: 114a vir j V&
Required spaces: n
Y /N
Items to be verified in the field:
Inspector:
Notes:
Date:
Viol ' s:
Y /VN
If so:
Pro
Y
Ifs t:
a dance:
y N
so, List: !
's:
/N
If so, List:
Clearances:
SDP's
I
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,G..d';-,N1``A-
Cou ty application name and n nber]
was provided to � '` �` - ® �� tIle of record of Tax Map
[name(s) of the record owners of the parcel]
�
and Parcel Number Q��eY " t' ®�''�C)- TYb T b3f 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]
on
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 f to the foll wing address: a
Dates
[address; written notice mailer 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].
\ �Nl ��7�7
Signature of Applicant
Print Applicant Name
Date
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