HomeMy WebLinkAboutCLE201200041 Legacy Document 2012-03-01n n
Application for Zoning Clearance_
CLE # W Z 41
y
A., -
PLEASE REVIEW ALL 3 SHEETS
jReceipt#
OFFICE U E O Y
Check # Date: 2 Zt 2
Staff:
PARCEL INFORMATION pp m/y
Tax Map and Parcel: 06 ' 1� Existing Zoning y
Parcel Owner: lCo r &&C,
Parcel Address: 60,90 1�ki J *" Aar k3�City C&A410AW11e State Zip Jj !/
(include suite or floor)
PRIMARY CONTACT %%��
Who should we call /write concerning this project9 y nchj / Celt W�L�q I�► S
Address: �Q�d ���� �GTI GOS�N► 1 y c ,30coity Ck&1a zo !(L State V61 Zip
Office Phone: OT Z Cell # Fax # 43q 6689 E -mail
APPLICANT INFORMATION
Check any that apply: V Change of ownership Change of use Change of name New business
Business Name /Type: �aCGUcWo� T 1.UVlQn Slu �� PG
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: Meottzp 0 #'C-r� f aVOA1 • /d ��
*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 knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature Y� rIQ/l �M Printed C! nG!Q/18�c!•
APPROVAL INFORMATION
Approved as proposed [ ] Approved with conditions [ ] Denied
[ ] Backtlow 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 determinaf ion. of compliance with the existing
site plan.
[ ] This site complies with the site plan as of this date.
Notes:
Building Official Date
Zoning Official l Date.
Other Official Date
County of Albemarle Department of community uevelopment
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
Revised 7/1/2011 Page 2 of 3
P. ,
Intake to complete the following:
Y 16?
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y eeWil ere 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 u ic?
If private well, provide ltlrep artment 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 ublii: sew ?
Y /
Will you be putting up a new sign of any kind?
Sign permit.
Permit #
If so, obtain proper
Y /
Wil ere be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zonin to com lete the following:
Reviewer to complete the following:
Square footage of Use: .7-5'V 0
Y/N
Permitted as: /11,'cao
Under Section:
Supplementary regulations section:
Parking formula:
vv N�-It
Required spaces:
Y/
Items to be verified in the field:
Inspector:
Notes:
Date:
Viol tions:
Y/
If so, ist:
Proffers:
/ N •
If so, List:
Ya� ia�ce:
(/
If so, List:
SP'si
Y {�
If so, List:
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3
CERTIFICATION THAT NOTICE OF THE
APPLICATION HAS BEEN PROVIDED TO THE LANDOWNER
This form must accompanj, 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,
[County application name and n mb_er]
was provided to the own ex of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number by
manner identified belo
a copy of the application in the
Hand delivering a cop of the application to /
[Namef the record owner if the record owner is a
person; if the owner of recor 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
if the owner of record is an entity, dentify the r
office for that entity]
on
Date
[address; written notice
the current real estate to
this requirement]. f
record owner if the record owner is a person;
kient of the record and the recipient's title or
to the following
sailed to the owner at the last known ' ddress of the owner as shown on
assessment books or current real estat� tax assessment records satisfies
Signature of Applicant
/ Print Applicant Name
Date
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