HomeMy WebLinkAboutCLE201500012 Legacy Document 2015-01-21Application for Zo ing Clearance'
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CLE # Z101 13 Z
N
PLEASE REVIEW ALL 3 SHEETS
OFFICE USE ONLY
Check# CQ Sl- Date: 1 ) y 1
Receipt # 1%-f O O Staff: D�2
PARCEL INFORMATION ))
Tax Map and Parcel: h -er ceA Q7 Existing Zoning �(c{ ,n rn.FC'1 'Dewe -1
Parcel Owner:
Parcel Address: aba A• bcnaA City C�CvW_2Sok State � Zip XM61
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project?
Address: l) -o i J Gruel J 6_v 10r City C c\ r lbk5yk State V-1 Zip a
Office Phone: ( y) �5 ' ' I Cell # '1-[zq 60LS C4�0 Fax # E-mail•^� S �n�� 12 (y, . Go
APPLICANT INFORMATION
Check any that apply: Change of ownerrship/ Change of use Change of name New business
I
BusinessName/Type: ��Tr��'7��. li7✓'�!°^ij 1�t�.� }-�o,v�i-�4.���10 l�i%�iC�� Sy��t5
Previous Business on this site C r1(A4-�&kt3
Describe the proposed business including use, number of employees, number of shifts, available parking spaces, number of
e7cuS
vehicles, and any additional information that you can provide: cf�A, y }'
*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 orJ ave the owner's permission to use the space indicated on this application. I also certify that the information provided
is true and at to the b 4 of my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature �l' Printed �yr�Sf
APPROV,�L INFORMATION
�Q 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.
[ ] This site complies with the site plan as of this date.
Notes-
Building Official Date
Zoning Official Date
Other Official Date
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (434) 972-4126
Revised 7/1/2011 Page 2 of 3
ram
Intake to complete the following:
Y /E)nLI,
Is usHI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y/N
Will 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 p �ivIf private well, provide Health 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?
Y it N
ll you 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 #
Zoning to complete the following:
Reviewer to complete the following:
n�
Square footage of Use:
i' / N - y
Permitted as: %tel A ,
Under Section:
Supplementary regulations section:
Parking formula: y I
�, e/
Required spaces: j
Items to be verified in the field:
Inspector : Date:
Notes:
Violations:
W/N
so, List: 1)
Proff rs:
Y/
If so, ist:
Variance:
t/N
If so, List:so,
)9--7 � v �
SP's:
6)/N
List:
30
Clearances:
SDP' s
U��2o1—
()- >.
Revised 7/1/2011 Page 3 of 3
•
Simple Comforts Store Layout
Rough Layout 13,000 total sq ft.
marle Square Shopping Center
Mbemarle Square
-lottesville, VA 22901
arcel 123
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,
was provided to
[County application name and number]
[name(s) of the record owners of the parcel]
and Parcel Number
manner identified below:
Hand delivering a copy of the application to
the owner of record of Tax Map
by delivering a copy of the application in the
[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 red pient'stitle 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].
ature of Applicant
u 1,7/15 so,
�d5 �
Print Applicant Name
Date