HomeMy WebLinkAboutCLE201300275 Legacy Document 2013-11-21Application for Zoning Clearance6,�'r
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CLE # MR �
OFFICE US fJ LY
(��'jj Date: 1,0 ' ' 1_5
PLEASE REVIEW ALL 3 SHEETS
Check #
Receipt # � Staff:
PARCEL INFORM O '
�
Tax Map and Parcel: Existing Zoning
Parcel Owner:
_ �Y�
Parcel Address:y „ / CitY State Zip
(include suite or floor)
PRIMARY CONTACT ����
':f-IAJ�;
Who should we call /write concerning this project? "�`�AeATZ�
D �1 i1l�D�� G� City e State
Address :
Office Phone: L__3 Cell # Fax # " E -mail rn e K /YYI7 i CpjnnCU�
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use ____Change of name V New business
Business Name /Type:
,
n j� Aid
Previous Business on this site '' """`
Describe the proposed business including use, number of employees number of shifts, avai ble par n spaces, numbers of
vehicles, d any dditional information that you can provide:
MD
*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 accurate to the best of my knowledge. I have read the conditions of approval, and II understand them, and that I will abide by them.
� 0 V) /�6M1217
Printed
Signature c,1
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:
'Cr T —
Building Official Date
Zoning Official Date
Other Official Date
County 01 Aloemarle jueparCmelI1 U1 %.u1u111U111Ly JUcV vl,....,..�
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
Revised 7/1/2011 Page 2 of 3
iA.
Intake to complete the following:
Y /1Is us LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y
n
Wi t e 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 r pu lic water?
If private well, provide He th -Depa ent form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that app
Is parcel on septic public 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 #
Z ' to com late the followin
Reviewer to complete the following:
Square footage of Use: 1-(i Z)
6/N
Permitted as: — ) -eLt,'
Under Section: ? -
Supplementary regulations section:
Parking formula: l y�
Required spaces:
Y/
Items �e verified in the field:
Inspector : Date:
Notes:
VIA
ions:
Y/
Ifs ,List:
Proffers:
Y7
If so, ist:
\
V.'ariance:
xOIN
If so, List:
SP's:
Y/
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,
[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
'and 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].
Signatur Applicant
�iqP A10 V06
Print Applicant Name
11 /Ao i 13
Date