HomeMy WebLinkAboutCLE201400095 Legacy Document 2014-06-02Application for Zoning Clearance
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OFFICE USE ONLY 1,
PLEASE REVIEW ALL 3 SHEETS
Check # L17 ( Date: 5 Z� 7
Receipt # Staff:
PARCEL INFORMATION f 7 �+
�j�j �L1 Existing Zoning C� t� i)�YYIQ %G1G1
Tax Map and Parcel: -
Parcel Owner: 11l CC)M{aor) 5
Parcel Address: d _ City s . State f �- . Zip 2"l o (
(include suite r floor)
-PRIMARY CONTA T.
Who should we call/write concerning this project?
Address: Iy/s- i� 1 r RJ i �� (C s , City State ki, Zip`Zj
Office Phone: (_� Cell # q(5- / Fax # E -mail � n�act C
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
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Business Name /Type: a- C /�j�155�9 ' t. U �/��� `►
Previous Business on this site -"
Describe the proposed business including use, number of employegs, number of shifts, availab�e parking spaces, number of
vehicles, and any, dditional infor\Tat'on that you ca provide: s XK- �t• .-� �• �^- �
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*This Clearance will only be valid on the parcel for which it is approved. If you change, intensify or move the us o a new location, a new Zoning
Clearance will be required.
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I hereby certify that or have the owner's pe ission to use the space indicated on this application. I also certify that the information provided
is true and accura to best of kno le dg . I hav read the conditions of approval, and I understand them, and that I will abide by them.
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Signature / Printed
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 K /,1-/ (>14
Zoning Official Date . �`1a 2-01 /
Other Official Date
County of Albemarle Impartment of t.omniumLy vc- luvillu-
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
Revised 7/1/2011 Page 2 of 3
.4-1
Intake to complete the following:
Y
Is OLL HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y
WiQtere 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 ub If private well,_provide Health form.
Zoning review can not begin until we receive apl
Dept. FAX DATE
Circle the one that ap ---
Is parcel on septic ublic sew r?
Y
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y Ptere Wi be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
7nninrr fn nmminlafp 1-hp fnllnwina.
Reviewer to complete the following:
Square footage of Use: 5-06
V/N /
Permitted as:
Under Section:
Supplementary regulations section:
Parking formula:
Required spaces:
Y/
Items to be verified in the field:
Inspector : Date:
Notes:
Violations:
/-N
If so, List:
Nofrs:
/-
If so, List:
Variance:
/N
If so, List:
SP's:�
Y /l)
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
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) -ofthe record owners-of 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].
Date
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