HomeMy WebLinkAboutCLE201400113 Legacy Document 2014-06-20Application f ®r Zoning Clearance
CLE# 2-014~ 115
OFFICE USE ONLY
PLEASE RE' VIEW ALL 3 SHEETS Check # '3Z 3 Date:
Receipt # Staff:
PARCEL INFORMATION
Tax Map and Parcel: () O `� ` 0 �� Existing Zoning
U�
Parcel Owner: // �� p� � %,� /,� I �/� �,�ft Pa' el Addres�/Oir � 17 JS !7"� /Vity � 1�` �"'— State
(include suite or floor)
?RIMARY C NTACT
Who should we call/ r e concerning this project? °
Address : State Zip
r
Ofce Phone: Cell # Fax # SSE -mail C r
a–
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name /Type:
Previous Business on this site
Describe the proposed business including use, number of employees�ni ts, available parking spaces, number of
vehicles, and any additional information that you can provide: ��a��
*Thi s Clearance will only be valid on the parcel for which it is approved. If you change, intensify or move tie use to a new location, a new Zoning
Clearance will be required.
I hereby certify that I own or leave the owner's permission to use the space indicated on this application. I also certify that the information provided
is true and accurate to the best of my knowledge. I-hlavvee read the conditions of approval, and I understand them, and that I will abide by iliem.
Signature (�'�Y "�-�l v Printed�I7�ISD� 4"
�i��
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 c Date
Zoning Official e Date 6/ °�
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
Ia�1
i.
Intlke to complete the following:
Y/N
Is use in LI, I-II or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y/N
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 or ublic wnte ?
If private well, provide Health went form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applie
Is parcel on septic or «bIic sewez
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 #
11
Reviewer to complete the following:
Square footage of Use; / J�f1
Yom! N�
Permitted as; f''
Under Section; Z
Supplementary regulations section:
Parking formula: //
Required spaces:
Y/
Items o be verified in the field:
Inspector
Notes:
Date:
Nonnig to eom teie she fo ow�11 ,
Violat' ns:
Y/
If so, Est:
Proffers:
Y/I
If so, List:
Varinnee:
(0)/ N
If so, List:
SP's:
Y/
If so, ist:
Clearances:
SDP's
Revised 7/1/2031 Page 3 of
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, C/
[County plication nam d number]
was provided to V the owner of record of Tax Map
[name(s) of t ie record owners of the p l] ,
7 ,4
and Parcel Numbe by de iI vering 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 .
Mailing a copy of the application to a
[Name of the r ord owe
if the owner of record is an entity, identify the recipient of the
office for that entity]
on
Date
to the following address:
e record o er is a person;
and the r ipient's title or
[address; written notice rn filed to the owner at the I asiknAn 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
Print Applicant jName
Date
W.
EXHIBIT "A"
Attached to the Lease Agreement between the UVA Foundation and Central Virginia Litigation, PLC dated R • 22! 2011
PREMISES FLOOR PLAN
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