HomeMy WebLinkAboutCLE201400059 Legacy Document 2014-04-24Application for Zonin Clearance
CLE #
F� `r -� ��' "''�
PLEASE REVIEW ALL 3 SHEETS
OFFICE USE ONI,�
Check # Date:
Receipt # 51 S 19 Staff:
PARCEL INFORMATION P 6/
Tax Map and Parcel: / Existing Zoningf I" 1
Parcel Owner: >
Parcel Address: tlJZ City State !/ T 1 Zi�
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project? � 110HF Az
Address • F(n LU6 L ° City K State Zip
Office Phone: &IBU6-11 Cell #i J6 2 VFax # E -mai
APPLICANT INFORMATION
Check any that apply: . Change of ownerships Change of use Chan of name New business
Business Name/Type: E"`''VV / - ( A&-6-E, a:03J
Previous Business on this site
Describe the proposed business including use, number of employees, umber of shifts, available parking spaces, number of
vehicles, and any additional ��orrip `tion that �� u�� j �rovide: /`1 %mil -moo= e'4 —1'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.
I hereby certify that I own or have the owner's ermission to use the space indicated on this application. I also certify that the information provided
is true " d ac rate to e best of my Im wle ge. I ve read the conditions of approval, and I understand them, and that I will de by them.
Signature . Printed /9 hL e P� zo
APPROVAL 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 Date
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 7/1/2011 Page 2 of 3
J
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/O
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 rivate wel r public water?
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 epti or public 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 renovations?
If so, obtain the proper Permit.
Permit #
Zoning to comDlete the following:
Reviewer to complete the following:
Square footage of Use:
Y)/ N
Permitted as: Alp
Under Section:
Supplementary regulations section:
Inspector • Date:
Notes:
Violations:
Y /1O
If so, List:
Proffers:
Y/A
Ifs , ist:
Variance:
Y/g
If so—, List:
SP's:
Y/6
If so, List:
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3
CERTIFICATION THAT NOTICE OF THE
APPLICATION HAS BEEN PROVIDED TO THE LANDOWNER
'his form must accompany zoning applications (Nome 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, �yI �j OUAI S l'f(J E 111 /
[County application name and number]
was provided to kjEl� i� the owner of record of Tax Map
[name(s) of the record owners of the parcel]
- - - - - - -
and Parcel Number / by delivering a copy of the application in the
manner identified below:
X Hand delivering a copy of the application to n,E)?)e6k,
[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 of,, iJce for that entity]
on T
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].
kti l 1( . /gtom'- G e gr4,r 195W
Print Applicant Name
01414-
Date
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