HomeMy WebLinkAboutCLE201200051 Legacy Document 2012-03-06Application for Zoning Clearance
CLE #
OFFICE USE Y
PLEASE REVIEW ALL 3 SHEETS
Check # Date: -
Receipt # Staff-
PARCEL INFORMATION �.
ox
Tax Map and Parcel: OSS F3 ° ox- (M - u-) Existing Zoning P! P,r'cP,r'c h �ruwd i_ e�
Parcel Owner: P" " c r k MWL\, 1c D(a -4f U�S � ,u_
Parcel Address: em , 609 3M City State 3M' y�' Zip Z 3
(include suite or floor)
PRIMARY CONTACT , ,/ , /
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Who should we call/write concerning this project? rye 1"'
Address: 100,!9 l �r� -�`^'� r� O4 C City C Y&A.L State Zip ZgZJ
Office Phone: (_) Cell# 434^ -18 /- ax# E -mail an,-)agEe rn1d 4rA:v1w Je-%.
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name _ , New business
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LJ
Business Name/Type: ea., rw at" fGeWa , Cc,. (reeyA lgs)n �Q
Previous Business on this site
Describe the proposed business including use, number of employees, number of shifts, availal a parking spaces, number of
vehicles, and any additional information that you can provide: V e � � a ��P : la a it f5
*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.
d4�
Signature Printed
APPROVAL INFORMATION
541 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 Date 3 I J 1 �-
Zoning Official Date
U
Other Official Date
County of Albemarle Department 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
.i'
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. ' / N ` (�
ermitted as:
Y
Wi ere 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
Is parcel on private well o nblic water?
If private well, provide Hea apartment form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applies
Is parcel on septic p is sewe '?
YJN
ill you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y /
Wi there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the following:
Parking formula: /
Required spaces:
Y/ .
Items o be verified in the field:
Inspector • Date:
Notes:
Violations:
U /N'
If so, List:
Proffers:
/N
If so, List:
Varia e:
Y/
If so, 1st:
SP's:
Y/
If so, ist:
Clearances:
SDP's
d� -419,
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
owner.
I certify that notice of the application, K&,., (,J hY e)C✓ &,I � (a. cum -4 SI - S VSS
[County application name and number]
was provided to ,rte I C—t Pro pov4 —� the owner of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number 6-4Z5C -- Q 1 --6 d — Mo C-6 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 & &t". b>"
[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 , . 6-0 L ZoIZ to the following address: P O ` 1� o k 37c)
Date I VA a)- 9 3 1;l-
[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].
S=,
Signature of Applicant
Print Applicant Name
a %19Siz
Date