HomeMy WebLinkAboutCLE201500022 Legacy Document 2015-02-26Application for Zonin Clearance
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PLEASE REVIEW ALL 3 SHEETS
Check # Date:
Receipt # Staff:
PARCEL INFORMATIO ,rye
Tax'Map and Parcel: da &?. _ 00-() I _-`'''7 T&V Existing Zoning
��V'[t� -' well l ��U�, !
Parcel Owner: 6 b�J
Parcel Address: W ��=o0,v0 Lht,16- City 4q� State V-A- Zip 0r
(include suite or floor)
PRIMARY CONTACT
9
Who should we call/write concerning this project.
e
State y%� Zip
Address:
Office Phone: AA !3l -?'��� # Fax # E-mail e✓�T1D 6er77t C_/WAea,
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APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name/Type: _.MD��
Previous Business on this site NAr
Describe the proposed business including use, number of employees, number of shifts, available parking spaces, number ofo
vehicles, and any additional information that you can provide:
*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 tha I own or have the owner's permission to use the space indicated on this application. I also certify that the information provided
dge. I have read the conditions of approval, understand and that I will abide by them.
is true and a:Mest ofw /and �them,
'I�
Signature Printed
APPROVAL INFORMATION
INN Approved as proposed [ ] Approved with conditions [ ] Denied
[ ] Backflow prevention device and/or current test data needed for this site. Contact ACSA, 977-4511, x117.
inspection has been done for this clearance. Therefore, it is not a determination of compliance with the existing
[ ] No physical site
site plan.
[ ] This site complies with the site plan as of this date.
Notes:
Building Official �— Date
Date
Zoning Official
Other Official v Date
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
IA\
Intake to complete the following:
Y G
Is use in LI, HI or PDIP zoning?
Engineer's Report (CER) packet.
If so, give applicant a Certified
Y AO
Will there 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 of ublic 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 a
Is parcel on septic ELpulblic sewer?
YO
Will 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 # Ps W I T' CO-10\P6(57(�D
z6/, -2y '7 A �
ZoninLy to complete the following:
Reviewer to complete the following:
Square footage of Use:
0/N
Permitted as: 's
Under Section:
Supplementary regulations section:
Parking formula:, Aja
Required spaces: 3
Y/
Item o be verified in the field:
Inspector : Date:
Notes:
Violations:
(rT)/6
If so,-ist:
Proffers:
if so, List:
Variace:
If so;Zist:
SP's:
If so' ist:
Clearances: SDP's
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
Administrator 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 V 1T10, C1=–TTk— the owner of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number (SS FYL- ft -0 O+U-0 by delivering a copy of the application in the
manner identified below:
Hand delivering a copy of the application to V Vy
[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 v t �U OiETTA
[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
to the following address:
Date
�-T'50 DW -3748 nth VA- 1-1010
[address; written notice mailed to the owner at the last known.addres's of the owner as shown on
the current real estate tax assessment books or current real estate tax assessment records satisfies
this requirement].
Signa ure of Applicant
Print Applicant Name
Date
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