HomeMy WebLinkAboutCLE201500005 Legacy Document 2015-01-15Application for Zoning Clearancet�,,-
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PLEASE REVIEW ALL 3 SHEETS
OFFICE USE ONLY
Checl( # Zb° 00100-5 Date: 1 /�
Receipt # q $ 14 Z Staff:
PARCEL INFORMATION
Tax Map and Parcel: C)` 660 " i%3' DQ - OOa f; Existing Zoning �4�ia�C2Ci1�L i f'f"3t✓
Parcel Owner: �t�t�i y�1i�R'( %C-RGLt ` �i
/(z0
PalcelAddress:So3 �'�a��eo���� Dr,.�Jxx�!tA City / , ffzLDTTrWli'16State \)A zip X103
(include suite or floor)
PRIMARY CONTACT
1/
Who should we call /write concerning this project.
Address: S03�f�J�bnl%CL�7'— ,��Z�CC{� City(,i Fi121��'iL -S�TZi State VA ZiPj97f 3
Office Phone:(11303� � �( Cell #iA34- ?QSGL( Fax #N3+3D6-s( ')il E-mail C'tne.t�e
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name /Type: L'S-K-`) C_-' RV �C E S
Previous Business on this site
Describe the proposed business including use, number of employees, number of shifts, available ppaarking` spaces, ngumber/ of
� `� ` �`� • 1 �l•�I \_V `�•Y��e
i t V 1..�'y�4J1.��.`Y a
vehicles, and�ny ad itional information that you can provide: iV.�" �
*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 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 to the best of my knowled e. I have read the conditions
�, Printed L e-s - �L i-E1 iZU�f Irk
Signature CA, ,' .r„� �.
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APPROVAL INFORMATION
[ ]Denied
�xT 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 foc• 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 Date
Date
Zoning Official K
`
Other Official
County 01 AlOCmarIC VU114I uALCiu w .w ...... .. ... .j [.... ----
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
Revised 7/l/2011 Page 2 of 3
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Intake to complete the following:
Reviewer to complete the following:
Y / b
Square footage of Use: 3-7
Is use in LI, H1 or PDIP zoning? If so, give applicant a Certified
/ N
Engineer's Report (CER) packet.
Permitted as:
P
Y /1
Will there be food preparation?
Under Section: 1
If so, give applicant a Health Department form.
Zoning review can not begin until we receive approval from Health
Supplementary regulations section:
Dept. FAX DATE
Circle the one that applies
�?
Parking formula:
Is parcel on private well or purb 1c wit.¢
If well, provide He�.lth- Dtrartment form.
private
Zoning review can not begin until we receive approval from Health
Required spaces:
Dept. FAX DATE
Y
Circle the one that applies
Items to be verified in the field:
Is parcel on septic or public 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.
Inspector : Date:
Permit #
Notes:
Y/N
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the following:
Violations:
Y /C)
If so, List:
Proffers:
Y/0
If so, List:
Variance:
Y/
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
Administrator Determinations or Appeals, Sign Permits, Building Permits) if the application is not the
owner.
I certify that notice of the application, ��P� -iC� 1r✓yJ� "- 2� °��`�L ��E'`''C"�`�C
[County application name and number]
was provided to t- �i i� �� the owner of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number 016CO-D3 0 - OC AS0 by delivering a copy of tile application in the
manner identified below:
Hand delivering a copy of the application to °50 jA0 � %LO&R yAV-'z 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 VCc i- OASEtt- c7� Old
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]
rl
Date
to the following address:
[address; written notice mailed to the owner at the last known address of the owner as snown on
the current real estate tax assessment books or current real estate tax assessment records satisfies
this requirement].
Signature of Applicant
Print Applicant Name
Date
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