HomeMy WebLinkAboutCLE201500035 Legacy Document 2015-03-04MhILEP 1N
A.pplicati®n for Zoning Clearance
PLEASE REVIEW ALL 3 SHEETS
OFFICE USE ONLY
Check # ! D ,6 -L Date:10111<
Receipt # P5611%... Staff:
PARCEL INFORMATION C 1
Tax Map and Parcel; 04 X 00 - Qp - 00 - 10900 Existing Zoning
Parcel Owncr:t,,,)&oU1&aic. USort&rES LSH ' CE C -C-- Qp'EIr r'F S,
ULDER,.syai 6F State 0 A Zip 2240
Parcel Address: ;J015-& L -a&, ROl7Y_ C°T City CL
(include suite or floor)
PRIMARY CONTACT �
Who should we call/write concerning this project? L99001L
Address:gC)1!;-JJ_ IZ"oj< C --r- City (W*L#rrCsviLLE-State Zip 2ZSII
Office Phone: 2 $2- 51 & L Cell # Fax Oq,4 ZOZ- S9 'E mail N1e,09AR M--� e -h,
APPLICANT INFORMATION
Check any that apply:p' Change of ownership Change of use Change of name New business
Business Name/Type: di 6aa PFiyS1�/�! TNERAl r;,
Previous Business on this site�lQjJ�
Describe the proposed business including use, number of employees, number of shifts, available parking spaces, number of
vehicles, and any additional information that you can provide: D uT Pp-rIF sl M. 6,o61e, .
*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 ]lave the owner's permission to use the space indicated on this application. I also certify that the information provided
is true and accurate to best of my knowledge. I have read the conditions of approval and I understand theemm,, and that I will abide by them.
Signature Printed '%✓ L• 1✓��13!PowL
APPROVAL INFORMATION
[>q Approved as proposed [ ] Approved with conditions [ ] Denied
[ ] Backflow prevention device and/or current test data needed for this site. Contact AC SA, 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 3 r3 4
Zoning Official Date, -,3/,Yd�
Other Official Date
Lounty o] A.ioemarieLepHruueiiLui %.viuuLwixLy
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (434) 972-4126
Revised 7/1/2011 Page 2 of 3
Inttlke to complete the following:
Y/19
Is use in LI, HI or PDIP zoning?
Engineer's Report (CER) packet.
If so, give applicant a Certified
Y/
Will t re 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 publ' r?
If private well, provide H merit form.
Zoning review can not begin until we receive approval from Health
Dept, FAX DATE
Circle the one that applies
Is parcel on septic o pu Iic sewer
Y/N
Will you be putting up a new sign of any kind?
Sign permit.
Permit #
If so, obtain proper
Y/N
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
ri„ r +. —Ipfe +hp-Fn11nw9nr1-
Reviewer to complete the following:
Square footage of Use: �'b 0
(9/N./ n
Permitted as: Al ed,14 o`t-k � e
Under Section:
Supplementary regulations section:
Parking formula: �__(L,
Zn� /L
Required spaces:
Y/
Items to be verified in the field:
Inspector
Notes:
Date:
(�V11M LV VV11A la.�a. �alv avaav i .,.
Violations:
Y/N(�
If so, List:
Proffers:
O/N
If so, List:
Z-5,
Variance:
Variance:
i)/N
If so, List:
VA
SP's:
Y/(i
If so, List:
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3
tl �
CERTIFICATION THAT NOTICE OF THE
APPLICATION IIAS BEEN PROVIDED TO THE LANDOWNER
TIAs form must accompany zoning applications (I-rome 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 16.14 C, -,i Ag 90m.,I Ca, aa.4 LLC -
f [County application name and number]
t-i�
was provided to /9DJ�C1 f a� S i 6- the owner of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number a q,5-64 -66roo - l U 9C D by delivering a copy of the application in the
manner identified below: ��^^
Hand delivering a copy of the application to �5aL
r ��[Name 6f the recoer if the recordowner`ts 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 a a / I,'
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]
on to the following address:
Date
[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].
*ignaturepplicant
//l J�'1 /�J L• i�pc�oo�
Print Applicant Name
� fDate f-
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OFFICE
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