HomeMy WebLinkAboutCLE201300274 Legacy Document 2013-11-21Application for Zoning Clearancer'��
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PLEASE REVIEW ALL 3 SHEETS
OFFICE US ONLY
Check # ( L.D Date:
LI) C I
Receipt # _ —h Staff:
PARCEL INFORMATIO
Tax Map and Parcel: �� ( _C,"' L 0_0 Existing Zoning PU
Parcel Owner: LaCW V i ��' �( (ASS ic9 ) �U t Jj t" < <— �
Parcel Address: � &J 0. ks Or S 1- I.0 a City &I ju V, 4I (' State V/4- Zip Q aW
(include suite or floor)
PRIMARY CONTACT j i
Who should we call /write concerning this project?
Address : 17 1��'�+ �a'IfS . U f S� 0 City %r V "I State Zip
Office Phone: t r1 �'A ( I I Cell # U � y� G'S 17 Fax # y� 18'� 1 3 ? 7E -mail C`�i'� � S VA) e f111 i ���
APPLICANT INFORMATION IJ
Check any that apply: Change of ownership Change of use Changerof name New business
Business Name/Type: J- ar lyj Svj k
Previous Business on this site �' b V4, ' , I [e IL
Describe the ;proposed business including use, number of employees, number of sl�xa s, available parking spac s, number of
I ct-
vehicles, and any additional information that you can provide: ()J.", c
iiQCrolijrCS . 3 �.^,PIdhCC�S !V /O �,4!'2,
*This Clearance will only be valid on the parcel for which it is approved. Ifyou 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 knowI d I have read the conditions of approval, and I understand them, d that I will abide by them.
/an'
Signature Printed f`md )e ��b,� ✓r`' —�
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 c 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
Intake to complete the following:
Y/0 Is u n LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y/
Will t 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 publt' is 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 appli
Is parcel on septic of public sewer?
YJ N
ill you be putting up a new sign of any kind? If so, obtain proper
Sign permit,
Permit # ��
Y
Wile be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the following:
Reviewer to complete the following:
Square footage of Use: Al %6
mitted as:
Under Section: '3--0 •41. /
Supplementary regulations section:
Parking formula:
Required spaces:
Y/
Item o be verified in the field:
Inspector:
Notes:
Date:
Violations:
Y/
If so, st:
Proff s:
Y /O.
If so, List:
Varian :
Y/
If so, List:
SP's:
Y/N
If so, ist:
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, JAM Cr 1%'C `-h "''
[County applica on name and number]
was provided to arlSvIl P SS' t_ r e 1 the owner of record of Tax Map
[name o) of the record owners of the parcel
and Parcel Number 63 16 6 — d 4 — C 1 % 0 9 UD by delivering a copy of the application in the
manner identifier) bellow: .
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
V----Mailing a copy of the application to L-Cll Sty, /le �Ass/0111C r Z,, , Y,,4 L L�
[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 i11 to the following address:
Date
[address; written notice mailed to the owner at the last knoWA address of the owner as shown on
the current real estate tax assessment books or current real estate tax assessment records satisfies
this requirement].
c%
Signature of Applicant
Print Applica Name
Date
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