HomeMy WebLinkAboutCLE201400195 Legacy Document 2014-10-08F rom
10/02/2014 10:50 #679 P.002 /003
COMMUNITY DEYELOPMENTI Fax d3d972026 Oct 2 201d 11:51am P002 /003
Application l
1
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PLEASE REVIEW ALL 3 SHEETS
OlF1FXCt USE ONLY
Check #f q b pate: 1��L/1 y
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Receipt #'g '7= Sctiff:
PARCEL INFORMATION�
Tax Map and Parcel: :_� Cp)� � � / � 60� existing Zonirt� I
1Psrcel Owner• t R /; owv lQ
Parcel Address:- � •� ;tt. 1`"t�t� City —z State \i A _,'dipZ'mi
(include suite or floo)-)
PRITNIARX CONTACT
Who should we call /write concerning this project? L/-
a State C;� dip
Address: _ s Ci<E�sI S � r � Vy it, lP' L ` , y 0 3
Office Phone: (N Cell # C 5f.3P x * F 34 `� �'� LU' G3 t t ? Vl 1
a -mail �� t 5 � � C? E � fLJt;�artGt.: •r�{}
APPLICANT LICANT INFORMATION
Check tiny that apply: Change of ownership Change of use Change of name _ New business
s
Business Name/Type:
Previous Business on this site
Describe the proposed business including use, number of emptovfes, number of shifts, available parts'ng spaces, member of
vehicles, and any additional information that you can V'de U p�lj,�j�,g
"This Clearance %vial oniy 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 QJ be required.
1 heml, sera£ at t own or vc the owner's pet�naission tot 5e the space indicated on this application. I also certify that the in;or , ation provided j
i5 true and c r e to the be ofi knowledge. I have reed the conditions Orapprev and I understand them, and that f will abide by them.
t
Sigraato e Printed /� j
.A PP AL INFORMATION �
j Approved as proposed ( ) Approved with conditions [ i Denied I
I [ 1 Backflow prevention device and /or current test data noodcd for this slie. Contact ACSA, 977 -»t5l i, x I l7. {
[ j No physical site inspection has been done for this cica.ran..ce. Therefore, it is not a determination of compliance with the existing !
site plan. t
i
[ ] 'his site complies with the site plan as of this date. t
1 Notes;
Building Official Date to f (�
zanilte Official Date
e
Other Official Date
I
County of Albermarle 1.r'epartment of Cotzttnunity Vevelopment
403 NWritire Road Charlottesville, VA 22902 Voice: (434) 296- 58321Ffcx: (434) 972 -4126
..... .. .......... ........... _ ....... _...............
Revised 1,111/2011 Page 2 of
.1•^
A
Intake to complete the following:
Y
Is C121LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y /
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 o ublic wa •.
If private well, provide Healt epartment form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that ies
Is parcel on septic r public sewer?
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y/N Lt
Will there be any w const ction or renovations?
If so, obtain the pro er Permit.
Permit #
Zoning to comnlete the following:
Reviewer to complete the following:
Square footage of Use: 6 k0
P/ N
mitted as: Q)DL\
Under Section: W m . I AM
Supplementary regulations section:
Parking formula:
Required spaces:
-Y- —N
Itektt6e verified in the field:
Inspector:
Notes:
Date:
Violations:
Y /NN
Ifs ).X2:
Pro
Y/N
If so, fit:
Variance:
Y /Q
If s, t:
SP's:
Y/N
If so, st:
Clearances:
CLE n
1q
SDP's
Revised 7/1/2011 Page 3 of 3
From: 10/02/2014 10:51 #679 P.003 /003
COMMUNITY DEVELOPMENTI Fax d3d9724126 Oct 2 2014 11:51am P003/003
CERTIFICATION THAT NOTICE OE THE
APPLICATION HAS BEEN PROVIDED TO THE LANDOWNER
,[his form must accompany zoning applications (fii'omc occupation, Zoning Clearance, Zoning
,,Administrator Determinations or Appeals, ,Sign permits, Building Permits) if the application is not the
owner.
I cert!P~ that notice of the application,
h j (County application name and number]
was provided to V 1
el VA #1z
S the owner of record of Tax leap
(nanne(s) of the record owners of le parcel)
// CS �
and Parcel Number (All —6 A � "�1 / - (�.. ®.: 6
. y delivering a copy-of the application in the - -- -
manner identified below:
_ Hand delivering a copy of the application to ��l L
(Nance of the record owner` if t e recor . 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
(]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 to the following address:
Date
(address; written notice mailed to the owner at the last known address of the owner as shown or.
the current real estate tai, assessment books or current real estate tax assessment records satisfies
this requiretnent],
A
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Print Applicant Name
2-1 r_,Q(9141
Date
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