HomeMy WebLinkAboutCLE201400068 Legacy Document 2014-04-22Application for Zoning Clearance�r�
CLE
OFFICE U O Y
PLEASE REVIEW ALL 3 SHEETS Check # Date: �l i
Receipt # Staff:
PARCEL INFORMATION t �brnr Gt
Tax Map and Parcel: M – Existing Zoning
Parcel Owner: ``
Parcel Address:
State Zil
(include suite or floor)
PRIMARY CONTACT }
Who should we call /write concerning this project?
Address : City - e State zip
Office Phone: L_) Cell # = 06'1 Fax 4 E -mail
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name ew business
Business Name/Type:
Previous Business on this site
Describe the proposed business including use, number of employees, number of hifts, available parking spaces, number of e
vehicles, and n add' IonaI information that you can provide: ` A
4
is 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 permission to use the space indicated on this application. I aiso certify that the information provided
is true and acc t to best of my knowledge. 1 have read the conditions of approval, and I d understand them, and that I will abide by them.
Signature Printe 1 1111.�-
APPROVAL I FORMATION
Approved as proposed [ ] Approved with conditions [ ]Denied
[ ] Backflow 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 `4 —
Zoning Official Date gill X26 1J
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 7/1/2011 Page 2 of 3
Intake to complete the following:
Y/
Is u Ll, W or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y/ Ere 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 or, ublic wat
If private well, provide Heal apartment form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that apLPUI lies
Is parcel on septic or=Sewer?)
l N
rll you be putting up a new sign of any kind? If so; obtain proper
Sign permit. _n MM
Permit #
Y N �
Wil ere be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zonine to complete the following:
Reviewer to complete the following:
Square footage of Use:
(�)IN
Permitted as: R !'
Under Section: 7-y , 2
Supplementary regulations section:
Parking formula:
Required spaces: / D
Itl
ltem o be verified in the field:
Inspector : Date:
Notes:
Violations:
YI
WSOLL t:
Proff rs:
YI
If so, ist:
I N
If so, List:
9 j �-
Varia ce:
Y 11
If so, List:
SDP's
Clearances'.
Revised 7/11/2011 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 ' 'O the owner of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number
manner ' entified 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].
k
Signature 9T Applicant
Print Applicant Name
Date
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