HomeMy WebLinkAboutCLE201200015 Legacy Document 2012-02-06Application for Zoning Clearance
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OFFICE U EON Y
7 1 '2b-12,
PLEASE REVIEW ALL 3 SHEETS
Check# Date:
Receipt # [ _ Staff:
PARCEL INFORMATION
Tax Map and Parcel: - b J�� fE Z --0 --0 b -= U Z- OJ O - - Existing Zoning C
Parcel Owner: C ro S (n o� (� ,n C C'.e'15-Q-v'
Parcel Address: _5 7 (.W Y - / v O �C ��� /U City e. i, o Zzr State y'4 Zip 7_21
(include suite or floor)
PRIMARY CONTACT
Who /write
should we call concerning this project?
Address: R b- BX City c-4- °7--c� State Zips' Ii
Office Phone: Cell C)Fax # E -mail "' °� �° <<` �� `°� des
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
n
Business Name /Type: -5 We-
Previous Business on this site
Describe the proposed business including use, number of employees, number of shifts, available �parkin g spaces, number of
vehicles, and any dditional information that you can provide: S G'� �s.�s -F
C(.ca ss es 1, a x `t L.o K 1C)7?--t1 *L i K
*This Clearance W_ ill on y 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 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 -e 1 Printed KZ a vt h e_
APPROVAL NFORMATION
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.
[ ] This site complies with the site plan as of this date.
Notes:
Building Official AJ �- 1 Date
Zoning Official Date
Other Official Date
k:ounty of Amemarle Impartment of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
Revised 7/1/2011 Page 2 of 3
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Intake to complete the following:
Reviewer to complete the following:
Y /
Square footage of Use:
Is us in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Will Vtere be food preparation? _ _ _ _
/ N
(Pei as: 6—A4'.
Under Section:___
If so, give applicant a Health Department form.
Zoning review can not begin until we receive approval from Health
Supplementary regulations section:
Dept. FAX DATE
SP's:
IC) /N
If so, List:
Circle the one that applies
Is parcel on private well or- public- rwoer?
If private well, provide Heaqth'Department form.
Parking formula:
Zoning review can not begin until we receive approval from Health
Required spaces:
Dept. FAX DATE
7
Clearances:
Y/N
Circle the one that applies
Is parcel on septic or.pu I is s r?
Items to be verified in the field:
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Inspector : Date:
Sign permit.
Permit #
Y / N
Notes:
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the following:
Viol ions:
Y /
If so, List:
Proffers:
Y j
If so, ist:
Variance:
Y&
If so, List:
SP's:
IC) /N
If so, List:
Clearances:
SDP'
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 (Some 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,
[County application name and number]
was provided to �'b Z�t 5 k 0? P � the owner of record of Tax Map
[name(s) of the record owners the parcel]
and Parcel Number by delivering a copy of the application in the
manner identified below:
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 1 < < (t Z to the following address:
Date
�z o. t 2- v- A Z29 32
[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].
a-�-1 pt-p- 9 0/�C&
Signatur of Applicant
', L, -z„ Q ,, ,., .e. 3 � o`�) e I I
Print Applicant Name
Date
1 t I l -2—