HomeMy WebLinkAboutCLE201400020 Legacy Document 2014-02-14Application for Zoning Clearancey'''
OFFICE U NLY ' f
Date:
PLEASE REVIEW ALL 3 SHEETS
Check #
Receipt # Staff:
PARCEL INFORMATION
/W /
Tax Map and Parcel: Existing Zoning X
,n �j
Parcel Owner:_%�L� � ��L� FLOLe
Parcel Address:�s-� 'i� �i � City Zip
(include suite or floor)
PRIMARY CONTACT a
Who should we call /write concerning this project? 0,M
Address : 7 5 QOW C4 I C -M 19— Dv, . City 5 y7u" I J--) State Zip
Office Phone: U Cell #C�ff3 �(�/ -Fax # E- mailnw,��W x.54 Ultif1�S�
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: R FTA-I L <:�:5 SYVI E'I—I CS
- En co
*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 accurat'o the best of ny kn ledge. I have read the conditions of approval, I understand them, and that I will abide by them.
Signature Printed /b`N�D (Z F GeT ��C
APPROVAL INVORMATION
�Q 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
Zoning Official Date Z / X //'.Zc /y
Other Official Date
County of Albemarle Department or uommumLy "eve►uYu1e1L
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 / �Ti
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 o4
water9
If private well, provide 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 septic or lic sewe
Y/N
ill you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y/N
ill there be any new construction or renovations?
If so, obt ' e r per4 a it.
Permit # i W'
Inn- +n nmm"lPl-P +hP fn1lnwin6!
Reviewer to complete the following:
Square footage of Use: `? V/
61 /N 1
Permitted as: ii4-A,
Under Section: A4 - �,✓AGz� C- 0 • ►1
Supplementary regulations section:
Parking formula:
q,,l
Required spaces:
Y/
Items to be verified in the field:
vg-
Inspector :
Notes:
Date:
/. -y
Vari ce:
Y/
If so, ist:
SP's:
Y / U
If so, List:
- aaa
Violations:
Y/
If sovList:
Proffers:
6IN
If so, List:
vg-
/. -y
Vari ce:
Y/
If so, ist:
SP's:
Y / U
If so, List:
Clearances:
SDP's 7—C� % %--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, 1Zzxfvrwcu2 J` , —,5zo / "1 ✓
[County application harne and number]
was provided to �iD�f�S the owner of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number
manner identified below:
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 L��1" c
[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]
o% to the following address:
ate
[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].
WIFRA:01A
1414b,ALQ dfl�E v A4j
Print Applicant Name
a �
Date