HomeMy WebLinkAboutCLE201500011 Legacy Document 2015-01-21Application for Zoning Clearance��,:_
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CLE #
OFFICE USE ONLY
Date:
PLEASE REVIEW ALL 3 SHEETS
Checic # 15'l 5
Receipt # 9 940 / Staff:
PARCEL INFORMATION Z
og— Existing Zoning
Tax Map and Parcel:
®Parcel Owner: 6500vw .Shaw's QusrnesS P,rIL- LLC -
'arcel Address: IS� y ✓" GIS 1i✓c1 City C w r ,le State Zip ZZ`/°•'
(include suite or flo r)
RIMARY CONTACT
Who should we call/write concerning this project? L -wre ce, C - M,-, rSii a tt
i
Address: 4132- 1q,,5e1eP(-:'y City State Zip
Office Phone: CY3� �3 --�i3( Cell # Fax # �---- E-mail / C-n-1� /bin Son 5
c/
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
G w f—S �, K l t $� ,�S Ly��t s c iir-� �n u1 b�✓�� o�'ref/
Business Name/Type: L LLC"
Previous Business on this site
Describe the proposed business including use, number of employees, number of shifts, available parking spaces, number of
L Sc /L ti wn ti t r St'r
vehicles, and any additional information that you can provide: �� ���.'
�Pr 5.P
$ ], rk Io✓° y lceG,�`cles tri%lets
*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
best knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
is true and accurate to the of my
Signature Printed
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. a
Notes:
Building Official X Date ( S
//
UW �� Date
Zoning Official A/"
Other Official v Date
't � D I meat
a- e -f -
County of Albemarle Department of Commune 3 eve op - - - -
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (434) 972-4126
Revised 7/1/201 1 Page 2 of 3
Intake to complete the following:
Y/N
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engine •'s Report (CER) packet.
Y
Will t 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(public water)
If private well, provide 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 septic or public sewer?
Y
Wil ou be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y
Wil there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zonin2 to complete the following:
Reviewer to complete the following:
Square footage of Use: /KUB
0/.N
Permitted as: t�l�lci ✓U�SI�y�SS o�t✓3Ce�
Under Section: Z -7'Z'
Supplementary regulations section:
Parking formula:�✓
Required spaces:
Y/N /
Items to be verified in the field:
Inspector : Date:
Notes:
Violati ns:
Y / tN
If so, List:
Pro fffIrs:
If so,Zist:
Variance:
If so, List:
SP's:
Y/N
If so, List:
6io
y
Clearances:
SDP's
�s-
6 Z --C-)
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
Allnliilistratol' Determinations or Appeals, Sign Permits, Building Permits) if the application is not the
o ivner.
I certify that notice of the application;
[County application name and number]
was provided to � Aovy 5 6 vs � n 2 S ! U
S f L L_ 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
[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
.5 novv 'S PI -5 S P—
v g a Mailin co of the application to
copy
[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].
S' ure of Applicant
Z,ce. V� S �i 't
Print Applicant Narne
/I` hf7l-
Date
SN 0,,, s F111- � lam, Ae
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