HomeMy WebLinkAboutCLE201400114 Legacy Document 2014-06-20Application for Zou* Clearance
CLE # 20 119
1&-
OFFICE USE ONLY
PLEASE REVIEW ALL 3 SHEETS
Check # Date:
Receipt # Staff:
PARCEL INFORMAT ON CAM
5 al) -- 0 0 " 0 J — X79 15 Li7Existing Zoning
Tax Map and ParcelQ:.
/
Parcel Owner: 4'V (100 (5 I'LL._ "Y'" 3S IX L � (_
Parcel Address: L� 1;9 b rJ;'P_ 6"_- i> .2 *(?City c V 1 "-a State \14— Zip 7-2--101
(include suite or floor)
PRIMARY CONTACT C jh�}� -t,� t�hi= .t�✓►2�"f
Who should we call /write concerning this project?
Address: l `]�J �}rJ�lJ �'� City State Zip - Z-?
y3 q �o . % 57( ��v -
Office Phone: ell # Fax # � 7 5 — i �`�� E -mail G C w(
APPLICANT INFORMATION
Check any that apply: of ownership Change of use Change of name New business
�Change
Business Name /Type: I 1 �!� W
JT
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 information that you can provide: N 2--- -^
*This Clearance will only be valid on the parcel fm- 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 1 or lave the owner's permission to use the space indicated on this application. I also certify that the information provided
is true and accurat o the bes of my knowledge.1 have read the conditions of approval, and I understand them, and that I will abide by them.
' �% �✓—
Signature Printed p
APPROVAL INFORMATION
Approved as proposed [ ] Approved with conditions [ ] Denied
[ ] Backflow prevention device and /or current test data needed for this site. Contact ACSA, 977 - 451.1, 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 _ - c Date 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
Intake to complete the following:
Y/N
Ts us- n T, HT or PDTP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y aD
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 private well r public water?
If private well, provide Hea epartment-f rm.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that appli
Is parcel on septic ublic sewer?
Y/N
Will you be putting tip 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: /S —')
d / N
Permitted as:' lk�e.,/
Under Section:
Supplementary regulations section:
Parking formula:
Required spaces:
Y/
Items to be verified in the field:
Inspector : Date:
Notes:
Violations:
Y/
If so'Zist:
Proffers:
Y/
If so, ist:
Varia ce:
Y /
If so, ist:
SP's•
if
If so, ist:
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 (Hone 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,
was provided to
[County application name and number]
the owner of record of Tax Map
[name(s) of the record owners of the parcel]
5 U
and Parcel Number (� — C-)' —va 'O �(j 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 �11��1
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].
Signature of Applicant
(', f&,7,-TV T-/
Print Applicant Name
IP/l &/J Y
Date
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