HomeMy WebLinkAboutCLE201500019 Legacy Document 2015-02-10vv% ��o �� y)%X
Application for Zo_nin Clearance��
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OFFICE USE ONL Z 3 15
PLEASE REVIEW ALL 3 SHEETS
Check # 19S Date:
Receipt # Staff:
PARCEL INFORMATION
Tax Map and Parccel :: O� (m 6-p0 0 - /2- C7 0I Existing Zoning ;P/)
Parcel Owner: 244 IN �
Parcel Address: _4 70 79•t^; PICLU C,+• -Ity 6k F4_P4DT1fS0(t tate
(include suite or floor)
PRIMARY CONTACT
Who should we call /write concerning this project?
� E�State ZfP
Address: aA) r �74J L �
Office Phone: (_� Cell (��J ax # E -mail W -('LD 9 I M L
APPLICANT INFORM ION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name /Type: 'W h� a D q)
Previous Business on this site 15p b r
Describe the proposed business including use, number of employees, number of shifts, available parking spaces, number of
fhb ti; S 10am -13
vehicles, and any additional information that you can provide: .Vi' ploy ,pd tr
(4 UPh1 'Pf
*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 ave the owifer's permission to use the space indicated on this application. I also certify that the information provided
to e b t of i kn )�vledge, I have read the conditions of approval, and I understand them, and that I will abide by them.
is true acrd ac�cur-ilte
N A�
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.
Notes:
Building Official Date
Zoning Official Date 265
Other Official Date
County of Albemarle Department of L.ommumLy Ueveiuh,,,c„L
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
Revised 7/l/201 1 Page 2 of 3
IN
Fm
Intake to complete the following:
Is/
Is us m LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet,
Y /
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 o pubh �,er,
If private well, provide Hea form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that p
Is parcel on septic r public sewer
Y / ly1
Will cu be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Reviewer to complete the following:
Square footage of Use: %2 Jai
(Y)/N
Permitted as:Z�� /
Under Section: �� 2
Supplementary regulations section:
Parking formula:
Required spaces: �j/'
Y/N
Items to be verified in the field:
Inspector : Date:
Y /
Will Ore be any new construction or renovations?
If so, obtain the proper Permit,
Permit #
Notes:
Zoning to complete the following:
Violations:
If so, List:
Prof(fe�rs:
If oXist:
Variance:
Y / N
If so, List:
SP's:
Y /
If so, List:
Clearances:
SDP's
Revised 7/1/2011 Page 3 of
CERTIFICATION THAT NOTICE OF THE
APPLICATION HAS BEEN PROVIDED TO THE LANDOWNER
This form must accompany zoning applications (Home Occupation, Zoning Clearance, Zoning
A(Iministrator Determinations or Appeals, Sign Permits, Builtling Permits) if the application is not the
owner.
I certify that notice of the application,
[County application name and number]
was provided to UW L ppai —\ / the owner of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number
. :A • d b 1
by delivering a copy of the application in the
manner enti f �e e ow•
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 / ,� I.
Date V
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].
Signature of Applicant
N n r�(A,(N
Print Applicant Name
Date