HomeMy WebLinkAboutCLE201300284 Legacy Document 2013-12-12Application for Zonin Clearance
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CLE#
OFFICE USE ON Y
PLEASE REVIEW ALL 3 SHEETS
Check # i
Receipt # f'
PARCEL INFORMA N
Tax Map and Parcel: (> r4 1- — 0, , 00 —G )L � o U Existing Zoning
Parcel Owner: Cov bCA— S �-Pp?T Cen%i'k/ LLc
Parcel Address: 512Y 71*1/ie. Ne&I$*OA n'A City "eat State V 6r- Zip
(include suite or floor)
PRIMARY CONTACT
1Gi. /Sle
Who should we call /write concerning this project?
Address; f 0 ( City _Wayac1 L• fa State V tq-
Office Phone: (42`x) 4(0 Cell # Fax # E -mail rAhCS
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name /Type:
Previous Business on this site
Describe the proposed business including use, number of employees, number of shifts, available parkin spa number of
rs r�s 16 �"
vehicles, and any additional information that you can provide: [%i �sj ..,�> �Oe- j�
*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 have the owner's permission to use the space indicated on this application. I also certify that the information provided
of approval, and I understand them, and that I will abide by them.
is true and accurate to th est of my knowledge. I have read the conditions
Signature Printed i4 ice,�l l'�GS l—
APPROVAL INFORMATION
>4 Approved as proposed [ ] Approved with conditions [ ]Denied
[ ] Bacicflow 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 /?-_ /r y
Other Official Date
County of Albemarle Departmeni oz i.vmu1U111Ly UUVV OpiI.u,.�
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 / /4I
Is u m LI, HI or PDIP zoning?
Engineer's Report (CER) packet.
If so, give applicant a Certified
Y /( N�
Wi -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
Reviewer to complete the following:
Square footage of Use:
-5-CZ11
�/ N ��, /
ermitted as: �`- 4NVA 7 R
Under Section: 4 Ppn, J2�;
Supplementary regulations section:
Circle the one that applies a�Ite�? Parking formula:
Is parcel on private well or p
If private well, provide Health Department form.
Zoning review can not begin until we receive approval from Health Required spaces:
Dept. FAX DATE
Circle the one that applies
Is parcel on septic or public sewer?
)// N
Will you be putting up a new sign of any kind?
Sign permit.
Permit #
Y/N
Items to be verified in the field:
If so, obtain proper
Inspector : Date:
Y � ^, Notes:
Wi e be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Z ' to com lete the followin
onm
Violations:
Y/N
If so, List:
Proffers:
Y/N
If so, List:
Variance:
Y/N
If so, List:
SP's:
Y/N
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
Lro 2vF S�^�PP�.•, 0?^46-,s 1j-(- the owner of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number
manner identified below:
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 y z� (� to the following address:
Date
P O i3 ox f L C1 Cro to � V A 0'�1
[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].
Signature of Applicant
Print Applicant Name
Date
(- 'yz')