HomeMy WebLinkAboutCLE201400167 Legacy Document 2014-08-29Applicati ®n f ®r Zoning Clearance
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PLEASE REVIEW ALL 3 SHEETS
OFFICE iaL
Check #
+Date:Receipt #91, C , i staff:
PARCEL INFORMATION &A 2 � � � Z Z '
) Existing Zoning �a�h Fawn �' +��'
Tax Map and Parcel:
Parcel Owner: t" 11 i `� �S�
S-7 6S- ! `t City. C-ro_"� _ State V Zip
Parcel Address: ,ucre.,.
(include suite or floor) t
PRIMARY CONTACT L
ASS
Who should we call /write concerning this project?
Address : 3J% t� tl' "`� �1=� ��JU�y�t City � 6Ze-�T- State Zip
Office Phone: Cell *_1j) -5Z6 Fax # E -mail fS e�e�►� �i �� ��
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APPLICANT INFORMATION
. Check any that apply: Change of ownership Change of use Change of name New business
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Business Name /Type: �� `'& ' "
Previous Business on this site
Describe the proposed business including use, number of employees, number of shifts, available a rking space, ytr tuber of
"t`1 �— �-(``t r-(�
vehicles, and any dditional informatl�io that you can provide: 5✓r ct,
*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 permissi to use the space indicated on this application. I also certify that the information provided
is true and accurate ry wle ve ead the conditions of approval, and I understand them, and that I will abide by them.
Signature Printed
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. • I
[ ] This site complies with the site plan as of this date.
Notes:
Building Official A r Date
j-���
Zoning Official Date �2�/ 2dl
Other Official Date
Uounty 01 A.lUernarie iieparimenz of t.omJnuulJy LGVUJVP1X1U1,L
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
Revised 7/1/2011 Page 2 of
0
IntaIse to complete the following:
Y / EI
Is use m LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y /
Will ere be food preparation?
If so, give applicant a Health Departnientform.
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 water
If private well, provide Healt n 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?
U/ N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y /5
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Reviewer to complete the following:
Square footage of Use: /3/0
It? /N•
Permitted as: Q'; ATG e
Under Section: ZO
Supplementary regulations section:
�UJ
Parking formula:
Required spaces:
Y/N
Items to be verified in the field:
Inspector : Date:
Notes:
LJVLL LlI LV Vvlll 1-
Violations:
Y
If so, List:
Proff rs:
Y/
If so, List:
Variance:
Y/N
If so, List:
SP's:
Y/N
If so, List:
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3
0
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 tine
o►vner.
I certify that notice of the application,
j� i _[C_ounty application name and number]
was provided to �� �1�5 the owner of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number 5-6 P r 0 1 ° '1.2 by delivering a copy of the application in the
manner identified below:
V/ Hand delivering a copy of the application to x""55 L
[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
V
!:�b I f v/
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].
Z.
Signature of Applicant
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Print Applicant Name
Date ko .
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