HomeMy WebLinkAboutCLE201400062 Legacy Document 2014-05-02Applicati ®n f ®r Zoning Clearance
CLE # z01 y
OFFICE USE ONLY O
PLEASE REVIEW ALL 3 SHEETS
Checic # Date:
Receipt # Staff:
PARCEL INFORMATION
Tax Map and Parcel: ^ 06'04(1— / /�C�O — /0id t� Existing Zoning _
Parcel Owner: LayeN fry,
y
Parcel Address: /05 6�'' 4 its is City C%1 „�% �% �� t! �� State V Zip L �9
(include suite or floor)
PRIMARY CONTACT
Who should we call /write concerning this project?
Address : � ��-% i�r�s� +z H iZ City G u j J [ <_ state V n Zip ZZ 9a
143 y
X06 e ire -.%c
Office Phone: 0/'36)1 `�c� "`/ �Sl( ell # Fax # E -mail ��i, �,
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:
*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 cert ify ttCafl oo i or have the owner' - pe�m�ission to use the space indicated on this application. I also certify th at the information provided
is true and accurate to the est of my kno edge. I lil he c onditions of appr-'ov l; understand e nd that I will abide by them.
�e;ead
TIV
Signature �. Printed C? �
APPROVAL INFORMATION
[ ]Denied
Approved as proposed [ ] Approved with conditions
[ ] 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. • I
[ ] This site complies with the site plan as of this date.
Notes:
Building Official - Date 't c
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
CERTIFICATION THAT NOTICE OF THE
APPLICATION HAS BE EN PROVIDED TO THE ]LANDOWNER
This form must accompany zoning applications (Home occupation, Zoning Clearance, Zoning
Administrator Determinations or Appeals, Sign Permits, Builtling Permits) if the application is not the
owner.
I certify that notice of the application,
[County application name and number]
was provided to
[natne(s) of the record owners of the parcel]
and Parcel Number
p.i tified below:
d d live►in a co of the application to
the owner of record of Tax Map
by delivering a copy of the application in the
an e g py
[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 ottne owner as snows uij
the current real estate tax assessment books or current real estate tax assessment records satisfies
this requirement].
signature of Applicant
Print Applicant Name
Date
Intake to complete the following:
Y/.
Is u 1n LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y /
Wili Here 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 publicNter?
If private well, provide H6W D_epa;finent form.
Zoning review can not begin until we receive approval from Health
Dept, FAX DATE
Circle the one that applies.__
Is parcel on septi - r public sewer
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y
W i
I t l t are be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the folIowin
Reviewer to complete the following:
Square footage of Use: _--/—, —/A
CD/ N.
Permitted as: rs
Under Section: 'A,Q M, _nl L�
Supplementary regulations section:
Parking formula:
Required spaces:
Y/N .
Items to be, verified in the field:
Inspector
Notes:
Date:
Viola ions:
Y /(i
If so, List:
Prof s:
Y/
If so, List:
Varia ce.,
Y
If so, ist:
If sist:
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3
s