HomeMy WebLinkAboutCLE201400177 Legacy Document 2014-09-1509110Y14 01:12AX
HP LASERJET FAX
P. 01
Applicabion for Zoning Clearance
010VICE US" 0 "Y
MEASE REVIEW ALL 3 SHLETS Check#
Receipt 7t EZ2
I OIZMA'flON
"EXR-RE—EL NF ----- e 0- T
rarest Owner: Tax MAP an -c -6 Existing zoninji,
....... U-0
Poreol Address: —,q�T;t
(-Z ZI 1) 2-2 qD'I
(include multe or (11>0 r)
PRIMARY CONTACT
Who9hould we coil/wHte concerDing this project?
V-1 \ e-
Addrcss-,_�'SIS9-- �nayv S11 __—Clty_�
Office Phone: 60(— Cell ft E-mail
APPLICANT INF ORMATION
Chnneo of name NeZ�;,;i7iW'
.Check any that o Ply! Change of ownerahir, Chan o of a,9e
-/ Z. - /3
Business NAmcffype:
11roviouo Business on this site
Describe the propoaed business including use, number ofemplo),ces, number of shifts,)mLilowe parking Spaces, number of
vehicles, and any additional information that you can pro-*,ide7 nl�jk�, r-= uj(44,
*'This Clearemoe will only be valid on ik: porcel for which it is opprovBd. If You 011fir8t, in(6nsifj or move. the use to a new location, a new Zoning
C)tumnct will be required,
I hereby =11Fy that I own or hayo iho owner's p-trinissiDn to use the Space indirmod on this application_ I also certify that the Lnformation provided
i,5 true and noourare to rho best of my knowI d9 -1 have read the conditions ol'approvO, and I under0and them, mid That I will obido by ffiom,
Printed
Q
APPROVAL INFORMATION
Approved as proposed Approved with conditions Den led
Ilackgow prevention dovice and/or current test data needed for thin slte, Contact A(:SA, 997-4511, x117,
No physical site inspection has boon done, for this clearance. Thereforo, it is not a deterinhiation of compliance with the existing
site plan.
[ j This silo compllt:y wish the site plan as of>;his date,
Notes;
Building Offlelai Date
Uning OfficiAl r-71 Dnte
.......... I
Other off1clal Date
County of All)etriarle Department of Community A.W010IMe"t
401 McIntire Road Charlot(eRville, VA 22902 Voice- (434) 296-5832 Fax! (434) 972-4126.
Revised 7/1/7.011 Page 2 of 3
Intake to complete the following:
Is/
Is us LI, HI orPDIP zoning?
Engineer's Report (CER) packet.
If so, give applicant a Certified
Y /N�
Wil 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 ublic water?
If private well, provide Healt i orm.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that appl' s
Is parcel on septic o public sewer?
Y / fN1
Will u 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 #
Zonin to complete the following:
Reviewer to complete the following:
Square footage of Use: - U D
J/N
Permitted as: 1oA, TAY /t�
Under Section: ZS Z
Supplementary regulations section:
Parking formula: S
Required spaces: 2r
Y/
Items to be verified in the field:
Inspector:
Notes:
Date:
nV,�iolations:
V/N
If so, List: ll
Proffers:
Y /(Nl
If so ist:
Variance:
Y /(N)
If soi``st:
/N
If so, List:
rE!'L
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,
[County application name and number]
was provided to
[name(s) of the record owners of the parcel]
and Parcel Number
manner identified below:
the owner of record of Tax Map
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]
lope
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].
Signature of Applicant
Print Applicant Name
1 Kt Pi'i 'R�J
Date