HomeMy WebLinkAboutCLE201400233 Legacy Document 2015-01-12Application for Z' oning Clearance��,:_''
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OFFICE USE ONLY
PLEASE REVIEW ALL 3 SHEETS
Check # C45 Y1 Dat e:
Receipt # GAO b Staff:
PARCEL INFORMATION Q
` 19 6 �-1 Existing Zoning
Tax Map and Parcel: :��
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Parcel Owner: [Tlr I��� Qa�K LLC
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Parcel Address:? � %�tLIU 25%f11�� C� City 0_4V_ WV1G,e State V6 Zip
(include suite or floo051t1Te 10.(
PRIMARY CONTACT �_
Who should we call /write concerning this project? t� 1l
120' City Tie C State � � Zip �3 7
Address (1
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Office Phone: 037) Cell # Fax # E -mail �C�CJ�
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APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name /Type:
Previous Business on this site
Describe the proposed business including use, number of employees, member of shifts, available parking spaces, number of
NO /� fkya Ewws'e
vehicles, and any additional information that you can provide:
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*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 lie owner's permission to use the space indicated on this application. I also certify that the information provided
of approval, and I understand them, and that I will abide by them.
is true and accurate he best f y ledge. I have read the conditions
Printed 1 TtAoAtNN
Signature
APPROVAL INFORMATION
[ ]Denied
Approved as proposed [ ] Approved with conditions
[ ] 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 DateT �{
l
Zoning Official Date
Date
Other Official
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
,Revised 7/l/201 1 Page 2 of 3
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Intake to complete the following:
Reviewer to complete the following:
Y / N
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Square footage of Use:�(i
Y)
ermitted as: r'-
/V? e�
Y �J
Will there be food preparation?
Under Section: 27.2.
If so, give applicant a Health Department form.
Zoning review can not begin until we receive approval from Health
Supplementary regulations section:
Varian e:
Y/V
If so, List:
Dept. FAX DATE
Circle the one that applies
Is parcel on private well r puZcwa r.If private well, provide Hea form.
Zoning review can not begin until we receive approval from Health
Parking formula:
J. 7 0 ��
Required spaces:
Dept. FAX DATE
Circle the one that ap li
Y/N
Items to be verified in the field:
Is parcel on septi or public se
Clearances:
SDP's
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Revised 7/1/2011 Page 3 of 3
Sign permit.
Permit #
Inspector :
Date:
Y V
Will there be any new construction or renovations?
Notes:
If so, obtain the proper Permit.
Permit #
Zoning to complete the followi
Violations:
Y /O
If so, List:
Proffers:
Y/
If so, List:
Varian e:
Y/V
If so, List:
SP's:
Y/
If so, List:
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3
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CERTIFICATION THAT NOTICE OF THE
APPLICATION HAS BEEN PROVIDED TO THE LANDOWNER
This form must accompany zoning applications (Home occupation, Zoning Clearance, Zoning
Arinzinistrator 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 the owner of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number
manner identified below:
by delivering a copy of the application in the
Hand delivering a copy of the application to 'St -3 -�
[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
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].
Print Applicant Name
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