HomeMy WebLinkAboutCLE201300222 Legacy Document 2014-01-06Application for ZoninLy ClearanceE
aC�`pY AL!lF�y
CLE 12-
OFFICE USE ONL
1,2) 1 I✓
PLEASE REVIEW ALL 3 SHEETS
Check # _ Date:
Receipt # Staff:
�
PARCEL INFORMATI 1C 1�`�.
Existing Zoning /
'��/��
Tax Map and Parcel:
�/ /� �j
Parcel Owner: U l or 6o, li t KJ
Parcel Address: /q3v (&1gy CI s irrl -/ City C94,,-t- -Y7700ulc State VA Zip'ZZCI
(include suite or floor)
PRIMARY CONTACT
Who should we call /write concerning this project? 2YAJ S-hw., TL
Address : 116.4 1716 -un4Dq PxYt City LYNC618ynG State d Zip 2y3a-L
Office Phone: Cell #(7u0678' qt V7 Fax # E -mail
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name /Type: 3 LW Y0 1��Z*- -N YQc vrLr
Previous Business on this site I1 OG? %z"N "?QGL&Vr
Describe the proposed business including use, number of employees, number of shifts, available parking spaces, number of
vehicles, and any additional information that you can provide: S'€Z,4 -50W45 ryzo-&J `_YCSCOtr
*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 I understand them, and that I will abide by them.
Signature Printed /c.r�t*/C'�''i�
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 Date _ ���(� (k3
Zoning Official _ Date 1/,/12�%3
Other Official V V Date
County of Albemarle impartment of l:ommumry lieveioprr►ei,c
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/N
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y ,GN ) M
Will there be food preparation?
If so, give applicant a Health Department form.
Zoning review can not begin until we receive approval onl e 0
Dept. FAX DATE
Circle the one that applies
Is parcel on private well o Cublic ter? If pr ivate well, provide Hene form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that a Is parcel on septic
Y yWill you u be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y / ITi
Will ere be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
7.nnina fn mrnnh -fP fhP fnllnwinn':
Reviewer to complete the following:
Square footage of Use: /dy J
CY)/N /
Permitted as: N
Under Section: &,q,2,)
Supplementary regulations section:
Parking formula:
Required spaces: � r
Y / /
Item\st6 be verified in the field:
Inspector:
Notes:
Date:
Violations:
Y /Iq
If so, ist:
Proffers:
Y/
If so, List:
Variance:
Y /(ICI
If so, List:
SP's:
J/N
If so, List: 4 Z
C� 7 -17
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 the owner of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number by delivering a copy of the application in the
manner identified below:
r 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 to the following address:
Date
[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 A Applicant
AfW S= Sc, M
Print Applicant Name
\ Date
Intake to complete the following:
Y /ON
Is use rn LI, HI or PDIP zoning? If so, give applicants. Certified
Engineer's Report (CER) packet,
Y �N J
Will ere be food preparation?
If so, give applicant a Health Department form.
Zoning review can not begin until we receive approval Rom Health
Dept, FAX DATE
Circle the one that applies
Is parcel on private well r ubIic wa
if private well, provide Hea t i epartment forin.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applies. —
Is parcel on septic ublic
YIN
Will you be, putting up a new sign of any kind? If so, obtain proper
Sign permit,
Permit #
4 YIN
ill there be any new construction or renovations?
If so, ob , r , rope geymil.,,,
Permit
;� •`iu• `L_ ..7,.4.. iL. .. 1'..17..
Reviewer to complete the following:
Square footage of Use: /i
61 N
Permitted as:
Under Section:
Supplementary regulations section:
Parking formula:
V J�
Re uired spaces:
Y/,
Items to be verified in the field:
Inspector : Date:
Notes:
Violations:
Y /�
If so, List:
offers:
Y / N
,. f so, List:
Vari, e•
Y/N
If s , ist:
SP`s:
�/N
so, List:
d,S 2
-'Cf ezi anccs:
SDP's
Revised 111/2011 Page 3 of 3
r.
Vt
`;:y,•,
1 3 P,
WV I A
1
A, ..i:.
1W
IM,
N
Mn
Avol coo
2 him, ova ;•. sw
li
....... ...
M x
. . . . ... ..
RNA C,
J. A
tot
gwo 00
ow
vivo
..........