HomeMy WebLinkAboutCLE201500040 Legacy Document 2015-03-06Application for Zoning Clearance�t�:_
CLE # Z015- Y O
PLEASE REVIEW ALL 3 SHEETS
OFFICE USE ONLY
Checic# 7VU-obo33Z(e Date: 7
Receipt # Staff: ?D
PARCEL INFORMATION
'" �� 7 �� Existing Zoning �►rnWC,a�
Tax Map and Parcel:
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Parcel Owner: \)6 r8 0�1
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��t"'�� �C<� �� City �(���'westate zip
Parcel Address:
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project?
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Address ca�C�Z��%�'aG\�ity��d�\State Zi '1
Office Phone: (H313 9'13-33("Cell # Fax #
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name/Type:
Previous Business on this site
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:
( �`
1
*This Clearance 'll only be valid on the pa el r which its 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
is true and accurate to the best of my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature�t' �liA i Printed (DS�C��
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.
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 Date
l,ounly 01 H1vuluallu "Up'l,
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (434) 972-4126
Revised 7/l/201 1 Page 2 of 3
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Intake to complete the following:
Y0
Is use in LI, HI or PDIP zoning?
Engineer's Report (CER) packet.
If so, give applicant a Certified
Y
WiQtre 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 u c water?
If private well, provide Hea Departmen orm.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applies
Is parcel on septicpublic sewer.
Y /r)
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y /
WillPtere be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the followin
Reviewer to complete the following:
Square footage of Use: 215-0
Y/N_p%) �0�
Permitted as: M ��=!
Under Section: 7 3_J
Supplementary regulations section:
Parking formula: � 4'0
Required spaces:��
Y/
Ite s d be verified in the field:
Inspector :
Notes:
Date:
Viola ions:
Y /
If so, List:
Proffer&s:
Y /'-,, i
If so, ist:
Variance:
AY/N
If so, List: �-t
SP's:
If so, List:
Clearances:
SDP's f
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, Building Permits) if the application is not the
o)vner.
I certify that notice of the application,
[County application name and number]
was provided to 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
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 snown on
the current real estate tax assessment books or current real estate tax assessment records satisfies
this requirement].
Signature of Applicant
Print Applicant Name
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Date
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