HomeMy WebLinkAboutCLE201400034 Legacy Document 2014-03-07Application for Zonin Clearance;rti
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aC� OF A1.IfFyy
CLE # 20) —
PLEASE REVIEW ALL 3 SHEETS
OFFICE USE ONLY
Check # 3%7 -57 Date:
Receipt # 9 4%1 (o Staff:
PARCEL INFORMATION,. J J
Tax Map and Parcel: j ' 7 Existing Zoning
Parcel Owner: Mj )iM b 1 G Ala[' y fY�Q CP LL
Parcel Address: (� i' `� CG m sv� �� �T -��� City ChA C 1 yt!4- %� -State Zip
(include suite or floor)'
PRIMARY CONTACT _p �
0, 'u A j2-6-:t
Who should we call /write concerning this project?
L' 5 ail wl -r S City C.'HO -ki e"Mrll)l -State Vf-L Zip Z2- f
Address :
Office Phone: '3 ' '% Cell # Z� "' 1 Fax # E -mail LY Ll'bnj�('�''L �t ! Q �J� 9-i
APPLICANT INFORM TION
Check any that apply: V Change of ownership Change of use Change of name New business
Business Name /Type: VAI yo C-V(LT
Previous Business on this site
Describe the proposed business including use, number of employees, number of shifts, avails le parking spaces, number of
Y
vehicles, and any additional information that you can provide: 1 )—Laj �fL^
, -
r-oLi. q n 1rV' C I (L L,,— L I-
*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. II have read the conditions of approval, and I understand them, and that I will abide by them.
Signature �"� """11 Printed 3I 0 1
APPROVAL INFORMATION
] Approved as proposed [ ] Approved with conditions [ ] Denied
[ ] Bacicflow prevention device and /or current test data needed for this site. Contact ACSA, 977 -4511, xi 17.
[ ] 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 -- t —`�
Zoning Official Date S /�LJ%A
Other Official Date
County of Albemarle Department of t:ommumty Levewpiueut
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 KN \
Is use m I, HI or PDIP zoning? If so, give applicant a Certified
En(gi er's Report (CER) packet.
YIt N!.
Will 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
Circle the one that applies
Is parcel on private well oiCublic �n�t If private well, provide Heaform.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that or �ublic se �
Is parcel on septic or ublic ✓seweo
Y N
Will y be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Will titer€ be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
7nn;nrr 1-n nntnnlntP 1-hp fnllnwinv-
Reviewer to complete the follow. ing:
Square footage of Use: DU .5j ' in
Y/N
Permitted as:
Under Section: —5
Supplementary regulations section:
Parking formula: —T-VA C'
Required spaces:
Y/
Items o be verified in the field:
Inspector:
Notes:
Date:
iolations:
so, List:
Proffers:
If so, List:
h1A
Variance:
Yl
If so, ist:
SP's:
d /N
If so; List:
Clearances:
SDP's
2 j
66—
Revised 7/1/2011 Page 3 of 3
I
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;
was provided to
[County application name and number]
[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 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 of Applicant
Print Applicant Name
Date