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HomeMy WebLinkAboutCLE201400003 Legacy Document 2014-02-06Application for Zoning Clearance�r, �'' CLE# 2614 -3 � L: PLEASE REVIEW ALL 3 SHEETS OFFICE USE ONLY Check # 26c1 `� Date: 1 Receipt # Staff: PARCEL INFORMATION ) j L Tax Map and Parcel: �i+7 (7 I /n A 05-(9 Existing Zoning �T Parcel Owner:_ &—(--�° D' n� 4l (i L � i� � Address: City ( Zi4Z `rG� Parcel (include suite or floor) PRIMARY CONTACT _ Who should we call /write concerning this project ?�rti�^ U �4•� "'" ` _ City �U. _ l n State V4 Zip Address: f yr�� Office Phone: 43 � �� Cell # �iCf ��`l r�0 Fax # '�� 9�Y ©��� E -mail Elk 01 ^41, APPLICANT INFORMATION Check any that apply: Change gf ownership Change of use Change of name New business _ens. rv1 l y� Business Name /Type:J�� Previous Business on this site& Describe the proposed business including use, number of employees, number of shifts, available parking aces number of i f-oy Cl-- vehicles, nd any ad itio ad infor tion that you ca provide: 5. n'N ' �C y 1(7 f r (ti:, C Z/\ ec *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 t use the space indicated on this application. I also certify that the information provided is true and accurZthe best of my knowledge ha - ad the conditions of approval, ann%d II understand therm, and that I will abide by them. -- Signature — Printed /`1'x°1 �/•�•(J� AP OVAL 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 31A C tli Date nn O� J101 Zoning Official Date Other Official Date County of Albemarle UeparCmeni OI 10111HIUMLy "CVl:IUPJ11V1Xl 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: Reviewer to complete the following: A Square footage of Use: " +- e in LI, HI or PDIP zoning? If so, give applicant a Certified Engineer's Report (CER) packet. P / N ermitted as: Y !� g Will there be food preparation? Under Section: �q. (� { �i1��5� (iV� If so, give applicant a Health Department form. Zoning review can not begin until we receive approval from Health Supplementary regulations section: Dept. FAX DATE Circle the one that applies Parking formula: ',A146 S (' Vr �I a `—'-.J Is parcel on private well o public water? '( �l If private well, provide Hea orm. Zoning review can not begin until we receive approval from Health Required spaces: Dept. FAX DATE Circle the one that appli Is parcel on septic or ublic sewer? Y/N Will you be putting up a new sign of any kind? If so, obtain proper Sign permit. Permit # Will N e e any new construction or renovations? If so, obtain the proper Permit. Permit # 7 A,- fnllnwinQ' Y/N Items to be verified in the field: uvaaau Violations: Y/N If so, List: Proffers: Y/N If so, List: Variance: Y/N If so, List: 's: Y/N If so, List: r Clearances: SDP's c-n J �� � Q Ljv i 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 manner identified below: by delivering a copy of the application in the Hand delivering a copy of the application to J [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]. Signature of Applicant Print Applicant Name Date C Applicant to complete the following: O/N Do you have one of the followaig? Tax Map and Parcel Number and or; Address of use (include unit or floor if apnrouriate; k' /N Do you have a'Floor Plan (sketch or an archkectural drawing) that includes the following, and if so pleasc provide it with the application? The total square footage of the use am `cr; g7he square footage of each mom or area of use: 'Use of each room or arts If using less than the entire structure, note the location wittli) the 54ructl rc. 0cr -,Z--fs &A� awe_ .Zoning Tech to Vtolati�na: Y / IN if so; List: Variance: Y/N If so, List: the Intake to complete the following: Y /r Is use in LI. H1 or ?DIP zoningi If so, give applicant a Ccrtined Engines Report ( '1ER) packet. Y ! a� Will(I,TjJ�yn,/ /eta he food preparation? If so, give applicant a Health Department fonn. Zoning review can not begin until we receive approval from Health inept, FAX DATE Y !' Is p cal on private well and septic? If so, give applicant a Health Department form. Zoning review can not begin until we receive approval from Health Dept, FAX DATE /N on public eater and 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 TeilovatiOns`! If so, obtain the proper Permit- Permit Permit > 411 +c Ct Yl� Is this for sales of Fireworks? If so, obtain a copy of F: k permit. Permit Y PYot%rs: Y/N If so, List: SP's: Y ! 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