HomeMy WebLinkAboutCLE201400011 Legacy Document 2014-01-30Application for Zoning Clearance
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OFFICE USE ONLY
# t SO Date: J u I N
PLEASE REVIEW ALL 3 SHEETS
Check a
Receipt # Staff:
PARCEL INFORMATION ,
0 5-( A �— ti GL — �1 � { % Existing Zoning 11
Tax Map and Parcel:
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Parcel Owner: ✓� � ✓�.0 j A/r'�t, L
2 G - � as °..
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Parcel Address: 5 T - 1 l yl�k. City
(include suite or floor)
PRIMARY CONTACT
Who should we call /write concerning this project?
City 3�� r--) State C� _ Zip
Address ,l
Office Phone: -C7 Ce1ti # X\ Fax # E- mail�Ie�Rc_�i���s-�Y
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 parking spaces, number of
vehicles, and any additional information that you can provide: S-7 Est Q-RA S<SX\
- nx -� y- i It 110—e
•rte -_ —�
*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, r�e iu d.
I hereby certify th t I 9 or have the owner's permission to use the space indicated on this application. I also certify that the information provided
the of approval, and I understand them, and that I will abide by them.
is true and accura e td the best of my knowledge. I have read conditions
/
Signature Printed
APPR AL INFORMATION
as proposed [ ] Approved with conditions [ ]Denied
?1Approved
1,13ackflow 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 I�
Zoning Official Date �lh— ZG f 1%
Other Official Date
U0 1nCy 0I Alnemarle vepaI LutGUL Ui t UiAu.auaa, y — F. -• ••-
401 Mclntire.Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
Revised 7/1/2011 Page 2 of 3
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Intake to complete the following:
OR
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y N
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 ublic water?
If private well, provide Healt form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that app
Is parcel on septic or ublic sewer?
Y'4
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit # U;, r G
Y }
Will t ere be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
7 1 .* + nnmriln4n +ha fnllnwina.
Reviewer to complete the following:
Square footage of Use: y !�
6) / N p
Permitted as: (54- C—
Under Section: )—O
Supplementary regulations section:
Parking formula:
Required spaces:
Y/
Items to be verified in the field:
Inspector : Date:
Notes:
X vV xl w v
Violations:
Y /`"
If so' ist:
Proffers:
Y /Nb
If so, List:
Variance-
Y/
If so, ist:
SP's:
If so,Zist:
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3
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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
the current real estate tax assessment books or current
this requirement].
-c
Date
cress of the owner as shown on
tax assessment records satisfies
of Applicant
pplicant Name
3
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