HomeMy WebLinkAboutCLE201400125 Legacy Document 2014-07-02N mw@
1�1, Zonin Clearance"=
Application for �
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CLE # d -125
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PLEASE REVIEW ALL 3 SHEETS
OFFICE USE _QNLY
Check# ��Q Date:
Receipt # D14n Staff:
PARCEL INFORMATION
Tax Map and Parcel: 06-1-P2— (5 l - DD - 00-30-D Existing Zoning N �� h ic3 M!4 Co ")v �me't -C; 4
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Parcel Owner: i� DE V�� f'n fi)JIn,Iahm
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Parcel Address:! XlY� t��i lltr�ri �' I City r10f - nth �e State �V� ZipV
(include suite or floor)
PRIMARY CONTACT ,� � is �� �.�•,� f P�
Who should we call /write concerning this project. . t fTc� r v�e"� E Le C
.� Z�ot
Address : ((YrG i v� t � City � V � � � State � � Zip
Office Phone: L( ` 3k ) Cell # -� Fax # E -mail e <<Z h��'�`� �i ��n�• Vic,.,
APPIICAN IINFORMATION
Check any that apply: Change off ownership Change of use Change of name New business
L ff
Business Name /Type: t �� f T _� t°�(� 11 P� LP(_ (���t'z`3o1
Previous Business on this site E A Ui 111 PSG
Describe the proposed business including use, number of employees, number of shifts, available parking spaces, number of
vehicles, and any additional information that you can provide: S c�-E ) S� 1® rob
i� ate °i fal 6" t vin ktss N .d of-,-
*This Clearance will only be valid on the parcel for 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 I own or have the owner's permission to use the space indicated on this application. I also certify that the information provided
is true and ac read the conditions of approval, and I understand them, and that I abide by them.
-will
Signature Printed l L �l - l Tl)t' ''� "e ✓
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
Zoning Official Date�� - /�N�
Other Official Date
County of Albemarle Department of Uommunrty 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 />
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y ' CN)
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 o ublic 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 o public sewer?
Y /0N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y �N�
Will��t ere be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the followinLy:
Reviewer to complete the following:
Square footage of Use: k54
I /N
ermitted as: O•�s
Under Section: 2,!V.2./
Supplementary regulations section:
Parking formula:
t /L�
Required spaces:
Y/�
Items to be verified in the field:
Inspector : Date:
Notes:
Violations:
Y/A
If so, ist:
Proffers:
Y/N
If so, List:
Variance:
]' /N
If so, List: 9
SP's:
Y/
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 (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,
moo) 0 G- C LQ1+kj40cC GC- Z-A
[County application name and number]
was provided to W N i WbyS,14 ,r V � c, rd u hct cam- 0^n the owner of record of Tax Map
[name(s) of M6 record owners of the parcel]
and Parcel Number d 5'� D2,- U 1-00 - 003c o by delivering a copy of the application in the
manner identified below:
X Hand delivering a copy of the application to TIM MS & � GL D U V � rQUf10(ccACn
[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-�:� S
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:
I 430A(�,5 L-HOL , 6-1
[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
film 12,0s&
Print Applicant Name
�
l2�ll�r
Date
PREMISES FLOOR PLAN
1 Boars Head Lane Suite B -1, 315 Square Feet