HomeMy WebLinkAboutCLE201400123 Legacy Document 2014-07-07f Z__
Application for Zonin Clearance
CLE#'Z0114 17-
OFFICE USE ONLY
PLEASE REVIEW ALL 3 SHEETS
Check # 1S % 9 Date ZG i
(a
Receipt # 4p) �% 1 St:
aff: Dzz
PARCEL INFOR
Tax Map and Parcel: Existing Zoning
Parcel Owner:
t j l
Parcel Address: City State Zip
(include suite or floor)
PRIMARY CONTACT
Who should we call /write concerning this project?
3 S_W— 5,.#_mt Ao d -e -Tr a, I City �r (041e V- %tate Zip
Address: -.
Office Phone: Y3 al 5� 17 to SCell #'�3y'98% OMS3Fax # q3y- 609 -I2i8 E -mail Ka1r -A yC-K scowl c -n
APPLICANT INFORMATION
Check any that apply: of ownership Change of use Y Change of name New business
rChange
Business Name /Type:
Previous Business on this site
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: We W1 II bay �.Setl cio 19 Si Iwv-,— c o7A.5. kt°w+_`
S+erh AA S. ilrer j¢ernS. SAX fintA(ayeeS w-, +lx one Sh-(Ft. 'here— eL r , 3Q p prlt,
aaeS &oi t I be— 5, ojeea a,rs .
is 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 accurate to the best of my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature Printed K a-�- W • 6.-u_cG l L
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 deterinination 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 �
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)
Is use in LI, HI or PDIP zoning?
Engineer's Report (CER) packet.
If so, give applicant a Certified
Y/
Will sere 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 blic at
If private well, provide Health epartment 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 ublic sewer?
Y I/ N
gill you be putting up a new sign of any kind? If so, obtain proper
Sign perb&--11 (1)
Permit #
YJ/ N
Will there be any new construction or renovations?
If so, obt ' rape t.
Permit # _ � Tl fa
Zoning to complete the following:
Reviewer to complete the following:
Square footage of Use: M D
1'ermitted as: 1iL)1 I �l C Sly i6�
Under Section: A4, f l % i� �! �� o4x s aR ---2-
P --,ajjl lions section:
Parking formula:
Required spaces: �3
Y/
Items to be verified in the field:
Inspector : Date:
Notes:
D Oro
X24 ?)SL0 l )-F -
Viol ns:
Y / N
Ifs ist:
Proffers:
Y nN
If sow 1st:
Vari ce:
Y / N
Ifs 1st:
SP's:
I fs , 1st:
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3
,40�
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, Z C7n i n � C /ea rGt n Cps
[County application name and number]
was provided to 1 e- LLLc-1z- 67 ro m-P LL-6-- the owner of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number O L' S p0 - 00 -0 0 - 10 6A Qby delivering a copy of the application in the
manner identified below;
Hand delivering a copy of the application to LLLc-k— 0 u> n er
[Naive 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 G Jo'g�
Date
Mailing a copy of the application to
[Naive 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].
, L "4/
Si ture of App icant
j a,nne-S
Print Applicant Name
/are hq
Date