HomeMy WebLinkAboutCLE201200026 Legacy Document 2012-02-06Application for Zoning Clearance
CLE #
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PLEASE REVIEW ALL 3 SHEETS
OFFICE US ON Y
Check # Date: ,L
Staff:
Receipt #
PARCEL INFORMAT ON r ]L p�
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tJ h Existing Zonin 111 M[y)(
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Tax Map and Parcel: { _ g g
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Parcel Owner: /
Parcel Address:,4t�g 56orn)Ot,,�5 City ARGe7l! Sr tL7 State 111A Zips[
(include suite or floor)
PRIMARY CONTACT
Who should we call /write concerning this project? ABEbii
Address :164 S 15A72V City A41A s- 3,o eP State ?/+ ZiPQ2
Office Phone: 7 Cell #fi,341, yP Fax # E -mail 1%&.,dLEfS�
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
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Business Name /Type: /Y/
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: .47- 7-A-63 %aME .vls�ld�EES
Nl- 5s�T
*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 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 knoow dge. I have read the conditions of approval, and I understand there, and that I will abide by them.
Signature �^--- �'�- -e Printed log e£T
APPROVAL INFORMATION
[ ] Approved as proposed [ ] Approved with conditions [F ];Denied
[ ] Backflow prevention device and/or current test data needed'for this site. Contact ACSA, 977- 451- 6117.
[ ] No physical site inspection has been done for this clearance. Therefore, it is t a determination of compliance with the existing .
site plan.
[ ] This site complies with the site plan as of this date.
Notes:
Building Official Date
Zoning Official Date'
Other Official Date
County of Albemarle Department of Community 1levelopment
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
Revised 7/1/2011 Page 2 of 3
.-11
a
Intake to complete the following:
Reviewer to complete the following:
Y / N
Square footage of Use:
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y / N
Permitted as:
Y /
�tere
SP's:
Y/N
If so, List:
Will be food preparation?
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
Circle the one that applies - -
Parking formula:
Is parcel on private well o public water.
Required spaces:
If private well, provide Healt epa Ent form,
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Y/N
Circle the one that appI'
Items to be verified in the field:
Is parcel on septic public sew
Y/N
ill you be putting up a new sign of any kind? If so, obtain proper
Sign permit. �, , j
Permit # W �j/�
P �
Inspector : Date:
Y / �)
Will there be any new construction or renovations?
Notes:
If so, obtain the proper Permit.
Permit #
7.,,,;,,rr 4n nmm"ln+a 4hp fnllnwimir-
Violations:
Y/N
If so, List:
Proffers:
Y/N
If so, List:
Variance:
Y/N
If so, List:
SP's:
Y/N
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 (Home 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,
was provided tb
[County application name and number]
[name(s) of the record owners of the parcel]
and Parcel Number
manner identified below:
Hand delivering a copy of the application to
the owner of record of Tax Map
by delivering a copy of the application in the
[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 shown on
the current real estate tax assessment books or current real estate tax assessment records satisfies
this requirement].
Siiggnnatu e of Applicants %
Print Applicant Name
Date