HomeMy WebLinkAboutCLE201300244 Legacy Document 2013-11-04ff^o 'n A n i.IL i L) br,) ) i;?
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Application i ®r Z ®nin Clearance�,L�
�~ OF Al. /IF.
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OFFICE U E 'ONLY
PLEASE REVIEW ALL 3 SHEETS
Check Date:
Receipt # ,., i (D Staff: — 1 c/y-( ,
PARCEL INFORMATION ++�`` , f
" � C�' Existing Zoning lif i i 1
Tax Map and Parcel: (,i� w� Y
Parcel Owner: A I WOif& "
- a �^� !�
Parcel Address: CUY) , 6md ' ,1 •, �/ � iir (U City ��i' _ State V ,� ZiPRI
(include suite o oor)
PRIMARY CONTACT M
' • t
Who should we call /write concerning this project?
I n
Address : (10 6 L4-) L�-� dd n K ve- Sk 4 City i� nr nns�� State VA_ Zip ?,?q K L
Office Phone: Sale 93Z ' / 5'01 Cell # `13Q* ,2.v `f 3 Fax # i3 • z - l s6) E -mail j�'i;�� i �l�� t, 'J", s
APPLICANT INFORMATION
New business
Check any that apply: Change of ownership Change of use Change name
Iof
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LO, cJ o A
Business Name /Type:
ab
Previous Business on this site
Describe the proposed business including use, number of employees, number of shiftsp available parking spa es, 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 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 ac e the�best of y knoyrjedge. I have read the conditions of approval, and I understand them, and that I will abide by them.
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Si nature Printed (•'� I S
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AP OVAL 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:
�— Date
Building Official
Zoning Official Date
Other Official Date
County of Albemarle Department of Community lveveiopment
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
Revised 7/1/2011 Page 2 of 3 ,
In ke to complete the following:
Y
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y / � er
Will 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 or ' wat •.
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 apgz;��.
Is parcel on septic or
Reviewer to complete.the following:
Square footage of Use: I LID
Q r N y�
mitted as:
Under Section:
Supplementary regulations section:
Parking formula: Li�
Required spaces: l 1
Y/N
Items to be verified in the field:
l°I / N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Inspector : Date:
Permit #
Y IQ Notes:
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit # Ris I )
17 re 4 lnfn fho fnllnwiner-
uwaaaa w v
Violations:
YIN
If so, List:
r ffers:
Y N
o, List:
b,
Variance:
YIN
If so, List:
SP's:
YIN
If so, List:
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3
(1666'
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,
[County application name and number]
was provided to
[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
[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
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].
I
��S��ig((n jat(ure of Applicant\
l
Print Applican Name
13
Date