HomeMy WebLinkAboutCLE201400091 Legacy Document 2014-06-20. I I bA ma
Applicati ®n f ®r Zoning Clearance
CLE#
Check # U -Tj� Date: FD A
PLEASE REVIEW ALL 3 SHEETS Receipt # r Staff:
PARCEL INFORMATIPIN I f /:5 3
Tax Map and Parcel: _
Parcel Owner:
Parcel Address: 7° go
(include suite or floor)
Existing Zoning__ 5 C
fi -5S-0C C-1 o
Y
City CI�A�CI -u State
7�SU
RIMARY CONTACT
Who should we call /write concerning this project? 3ro S G I° i 1
v✓ ?LV:P City i-'f 2CDiv State Zip 2-0-01
Address: 11" Cc4Q6wjo
GH
E -mail E��tfc� Y,8
Office Phone: C-24) Z �'S° [ I Cell # �° 3- �ZSS'° I Fax # —
APpLyCANT INFORMATION New business
Check any that apply: Change of ownership Change of use Change of name
_ S Wa12�S SfRUiFS
Business Name/Type: � ` -�` � N � � �`� S
Previous Business on this site_` i 4 So N
Describe the proposed business including use, numbe
canr provide:
employees, number of shifts, ailable number b+f �R
vehicles, and any additional information that you f P .& ' D _ i .0
*This Clearance will only be valid on the parcel
Clearance will be required.
I hereby certify that I own or have the own have read the conditions indicated app oval, and I and stand theme an d that I will abide byothemevided
is true and accurate to the best of my knowledge. �c � & �- x. /9`5
Printed i 00 J+
Signature
it is
or move the use to a new location, a new
APPROVAL INFORMATION Approved with conditions [ ] Denied
Approved as proposed [ ]
nBackflow 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.
�— Date
Building Official /
Date
Zoning Official
Date
Other Official
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
Is u m LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y 1
Wi 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 or public water?
If private well, provide 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 septic or public sewer?
'/N
Will you be putting up a new sign of any kind?
Sign permit.
Permit
If so, obtain proper I
Y/N
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Reviewer to complete the following:
Square footage of Use: > d�
!�/N %
Permitted as:
Under Section:
Supplementary regulations section:
Parking formula:
Required spaces:
Y/
Items to be verified in the field:
Inspector•
Notes:
Date:
Zoning to complete the following:
P roffers:
N
/ N
so, List:
List-
's
Variance:
/ N
�/ N
List:
I so, List:
o,
SDP's
Clearances:
Revised 7/1/2011 Page 3 of 3
CERTIFICATION THAT NO'T'ICE 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 ame and number]
was provided to
S #*(M G CrN -(072 ^5o& °� - wrier of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number
manner identified below:
� i f [ 3 3 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
(/ Mailin g a copy of the application to S �
[Name of the record owner if the h6cord 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 / /% to the following address:
Date
[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].
Sign Vrf pplicant
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Print Applicant Name
Date
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