HomeMy WebLinkAboutCLE201400067 Legacy Document 2014-04-22Application for Zoning Clearance
OFFICE USE ONLY ,�� y
PLEASE REVIEW ALL 3 SHEETS Check# 1q5;5 Date:
Receipt # 95751 Staff:
PARCEL INFORMATION
Tax Map and Parcel: C) 0' OG 5 0`J Existing 'Zoning_
Parcel Owner: II
Parcel Address: G� 1 ('� _ t—t Ave City �f,jLr4 State Ztpu
(include suite or floor)
PRIMARY CONTACT project?
Who should we call /write concerning this
7 i'
Address: � � City ruA�/� State V _ Zi^p� V 1.3
Office Phone: f ''/ Cell #'� V f • Fax # /U --E-mail �N[WD�cx�t - n✓ C-nw �
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 1 y (r
Describe the proposed business including use, number of employees, number of shifts, available parking spaces, number of
vehicles, and anyMdi Tonal information that you can provide:
r,'
"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.
1 hereby certify that I own or have the owner's pe fission to use the space indicated on this application. I also certify that the information provided
is Irue�flH -tathe best of y wledge. a read the conditions of approval, and I understand them, and that I will abide by them.
�
Printed �
Pr�� • 1
Signature � --
APPROVAL INFORMATION
>c Approved as proposed [ ] Approved with conditions [ ] Denied
[ ] Backf]ow prevention device and /or current test data needed for this site. Contact ACSA, 977 -4511, x 117.
[ ] 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 / x
Zoning Official Date
Other Official Date
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice; (434) 296 -5832 Fax: (434) 972 -4126
Revised 711120I 1 Page 2 of 3
Intake to complete the following:
Y
Is use t I, W or PDIP zoning? if so, give applicant a Certified
Engineer's Report (CER) packet.
Y
Will 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 public water.
If private well, provide Heal form,
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that
Is parcel on septic , publnswer?
Y N
Wil a putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
YIN
Wi be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoniniz to contnlete the following:
Reviewer to complete the following:
Square footage of Use: U
wU��t
1 N Shy,
ermitted as: 4 — tJto✓p^, c
i
Under Section:
Supplementary regulations section: , ,�
Parking formula: / I N -+
Required spaces:
YI
items to be verified in the field:
Inspector : Date:
Notes:
Violations; Proff s:
IN Y1
If so, List: If tst:
r
V riance: SP's:
31 N (9 I N
If so, List: �s1 If so, List:
tf -
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
manner identified below:
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 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].
4
Signature of Applicant
Print Applicant Name
#IAA` 1U
Date
RECEIVED
APR 11 2014
COMMUNITY
DEVELOPMENT
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