HomeMy WebLinkAboutCLE201500032 Legacy Document 2015-03-05Application for Zonhn..g "'ear-naz ce
—33—
GIF,t'ICE USE ONLY
checUl 9005
PLEASE REVIEW ALL 3 SHEETS
Receipt fl�
PARCEL INFORMATION
Tax Mal) and Parcel: (=:I I I -- existing Zoning -
P -
Nircel Owner: '--I L
7z -2—'w, VA Zip
—state
Parcel Address:
(irlClUdC Suite or floor)
PRIMARY CONTACT
nex
Who slioulci we can/write concerning this project`?
—zii) 2-zqi
2-667:,�� Loci<vvo ' C �J�
it)
Address -ovilke,
Cell 4 Fax # E-mail -9cc
Office Plion e; C---) —
APPLICANT INFORMATION
Check any that apply: —V�—Change ofownership _Change ol'use Change of name New business
Business Name/Type:"
Previous Business on this sit'—5 GLG rie"
Describe the proposed business including use, number ofeniplo),ecs. number ofshifts, avaitable parking spaces, numbei-of
e,f J
I ddlitional information th4t fl, pi-ovide: jl-��'(Zcco fl�6
c I —
vehiel 'you
WLC
*This Clearance will only be valid on the parcel for which it is approved. If you change, intensity or niove, the use to a new location, a new Zoning
Clearance will be required.
I hereby certify that I ow have the(n, er's permission to use the space indicated on this application. I also certify that the information provided
"1 0" them.
is true and accurate to the be, t of my I ledget I Jim cad the conditions of approval, and I understand them, and that I will abide by
'r
-.-"_
Printed
Signature
APPROVAL INFORMATION
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. - I
[ ] This site complies with the site plan as of this date.
Notes:
Da to
Building Official
Date
Zoning Official
Other Official Date
County of AlbernaflL Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fam (434) 972-4126
Revised 7/1/2011 Page 2 of 3
Intnlce to complete the following:
Y /
Is use n LI, HI or PDIP zoning? If so, give ,y)plicant a Certified
Engineer's Report (CER) packet.
Y /0Wil sere be food preparation?
If so, give applicant a Health Department fbrrn.
Zoning review can not begin until we receive approval from health
Dept. FAX DXrE .�
Circle the one that applies
Is parcel on private well o public wat ?
If private well, provide Flea partment form.
Zoning review can not begin until we receive approval from Health
Dept. I+AX DATE
Circle the one Chat ap lies
Is parcel on septicpublic'sewer
Y/N
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 #
1/
Reviewer to complete the following:
Square footage of Use: -
6/N l
Permitted as:
Under Section:
Supplementary regulations section:
Parking formul�
Required spaces: �V
Y/ V
Items to be verified in the field:
Inspector:
Notes:
.Date:
�onzn -co coin; iuty ULV Av11Vtr1116.
Violatr s:
Y /
If so, List:
P1•afl' s.
If o, .List:
e:
Y / �
If so, List:
SPISVaria
Y Id
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 (Horne occupation, Zoning Clearance, Zoning
A(Irninistrettor Determinations or Appeals, Sign Permits, Building Permits) if the application is not the
0101 er.
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:
the owner of record of Tax Map
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 .
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 availed 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 f
Print Applicant Name
Date