HomeMy WebLinkAboutCLE201400077 Legacy Document 2014-06-03� 4w
Application for ZQnin Clearance
7 a,�
OFFICE =8F7 PLEASE REVIEW ALL 3 SHEETS Check # Date: Receipt # Staff.
PARCEL INFORMATION
Tax Map and Parcel: -i ? 6U _ 6.1. Oo - U 0 Jo Existing zonin
Parcel Owner:UJ,,) dt O..v-L-t PY-6 C- y 4 t T �'n�' �.�r� D (Yo .sr-rti 1'
Parcel Address: G O C+ V, City CA-:,r, JL, State V G �
EP �' —
(include suite or floor)
PRUUARY CONTACT
Who should we caWwrite concerning this project? U r,
Address :!1, LP f " City State _ U c _ 22P LzftLf
Office Phone: (N� g'ri -3 i '} r Cell # Fax # entail
APPLICANT INFORMATION
Check any that a I3" Change of ownership Change of use Change of namef New business
Business Name/]We: -{'► 5 - n rL Slna ~�r 9- e s
Prevlous Business on this site
Describe the proposed business including use, number of employees, number of shifts, available parldng 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 anew location, a newzomng
Clearance will be required.
I hereby certify that I own have the owner's permission to use the space indicated on this application. I also certify that the infarmationpmvided
is true and accurate to th t of my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
St�mature Printed a cP S lti. U
APPROVAL MFORMATION
[ ] 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 Wsdng
site plan.
[ ] This site complies with the site plan as of this date.
Notes;
Bnnftg OfSchd Date
Zoning Official Date �g /21L1
T
Other Official Zt� Date �G
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:
Yl
Is us n LI, HI arPDIP zoning? Ifso, give applicant a Certified
Engineer's Report (CER) packet.
Y 1
Will It sere be food preparation?
If so, give applicant a Health Doorhnentform.
Zoning review can not begin until we rece[ve approval from Health
Dept VAX DATE �^
Circle the one that applies
Is parcel on'private well or blic venter
If private well, provide Health e nt form.
Zoning review can not begin until vie receive approval from Health
Dept, FAX DATE
Circle the one that applids
Is parcel on septic or pi 9 se;P
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
R viewer to complete the following:
Square footage of Use: -1y v
I N - 7J
Perinitled as: s 5dr: ems
Under Section: Rj -&e4 i r3�.
Supplementary regulations section:
Parking formula:
Required sptiow:
Y/
items-6 be verified in the field:
Inspector : Date:
Y / N Notes:
Wil l there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the following:
Violations:
Y1 M
If sa t:
Proffers:
Yl
If , st: .
riance:
kYj / N
If so, List:
SP's.
Y /
If so, at:
Clearances: - -
SDP's
Revised 7 /1/2011 Page 3 of 3
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CERTIFICATION THAT NOTICE OF THE
APPLICATION HAS BEEN PROVIDED TO THE LANDOWNER
This form must accompav zoning applications (Horne 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, 2,o v% k rVA C. [ U4,1r-
Pro [County ication name and number]
was provided to LjJ,) o J0L *-4 r ro • the owner of record of Tax Map
[name(s) of the record owners of the parcel]
`7ell7 p-6
and Parcel Number . _ by delivering a copy of the application in the
mmmer identified below:
Hand delivering a copy of the application to
[Name of the retard 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
Mailmg a copy ofthe application to (_ 00 clo. -,r-&
[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 5 - .5 l to the following address:
Date
;3�- -�L- �f I q +-&- J t N. Uj .0 __.. � 1c, 1 , LA . 2.Tsr 03
[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].
Signature of Applicant
A ` -S 4- r
Print Applicant Name
S I Lf
Date