HomeMy WebLinkAboutCLE201400090 Legacy Document 2014-05-22L19M
Application for oan* Clearance
CLE # o I
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PLEASE REVIEW ALL 3 SHEETS
OFFICE US � ONL ✓ �� t�
Check # d Date: ti 1
Receipt # qEjvq4 Staff: UNK&I
PARCEL INFORMATION
Tax Map and Parcel: TGxO farce/ 3S Y Existing Zoning LL
Parcel Owner: :5OIO l'iS 84S/X60
Parcel Address: /-5'/Z V / � �Gi A/O City N01'14J'VAe State VA Zip ZZ9 O -
(include suite or floor)
PRIMARY CONTACT - - -- -- - — - - -- - -- --- -- - -- - - - - -- Who should we call/write concerning this project?
Q%% /�
/� /� / ' /�AU�a
Address : /S/L V 0/a W,%4,e City ,4ha ✓!a 4& State V7`t Zip ��Z
I
Office Phone: Cell # ?( ?-311- 175JFax # �— E -mail QXurew S'Djr Cof(e
— _�
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of New business
Jname
Business Name /Type: �Pj� Co4�2l�1�2, �iaGt. 5T 0Y2y0(�_ -(G 1vPel ecom
Previous Business on this site
Describe the proposed business including use, number of employees, number of shifts, available parking spaces, number of
vehjcles3 and ny, additional information that you can provide: S� 0 2
*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
them, and that I will abide by them.
is true and accurate to the best o my knowledge. I have read the conditions of approval�anddII
understand
Signature Z=:== Printed ✓d JN �0 n
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 �,o �(
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
Intake to complete the following:
�)/ N
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y /�Will ere 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 o publier?
Ifprivate well, provide Heal �, P„a ment form— — _ -- - - - -_ - - --
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that lies
Is parcel on septic r_ lic e .
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 complete the following:
Reviewer to complete the following:
Square footage of Use: 6 S / g o
j/N
Permitted as:
Under Section:
Supplementary regulations section:
Parking formula: / u
Vt Required spaces:
Y/
Items to be verified in the field:
Inspector : Date:
Notes:
Violations:
Y/{N
If so, List:
Proffers:
Y/ ,
If s , ist:
Varian e:
Y/
If so, List:
uts:
Q� /N
If so, List:
ct
�YII'
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, zor l)yq
[Coup application name and number]
was-provided-to SY1 t7W 5 S, f 'Pork O t� he owner of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number j61C al / 20 Reel 355� by delivering a copy of the application in the
manner identified below:
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
-a—/Mailing a copy of the application to p 6e. { + JY OV-)
[Name ot 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 5//5Z/Zz to the following address:
Date
C)7- �SAOL-) I&I
[address; written notice mailed to the owner
the current real estate tax assessment books-
this requirement].
Ax
1 zZ9 �1
the last knoVh address of the owner as shown on
current real estate tax assessment records satisfies
Sign re of Applicant
Print Applicant Name
��1y
Date
\0
(V)
N,
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