HomeMy WebLinkAboutCLE201200054 Legacy Document 2012-03-09Application for Zoning Clearance
CLE # �4-
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OFFI CE LY
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PLEASE REVIEW ALL 3 SHEETS
Check # V Date:
Staff:
Receipt #
PARCEL INFORMATION
Tax Map and Parcel: y J G — Existing Zoning 6-1 �y �^� m� rt a
Parcel Owner: )C)
J 5'�(6Y cf �b}�eSv I,� z2�J %l
Parcel Address: � 2� C �r� e%S � 1 u^ ^ Cit �t � i �. State � Zip
(include suite or floor)
PRIMARY CONTACT _
Who should we call /write concerning this project ?�li 1 +� [i y �� U61�
Address 0 LLj pl City P3 A- 03l7t. Z. J j State V Zip AQq
Office Phone: L__) Cell # y 3q gq j6q( ax # E -mail
APPLICANT INFORMATION
Check any that apply: Change of ownership, Change of usse Change of name New business
Business Name /Type: l �� N Q,� (nJ Act 50
t' "o' ' "J
Previous Business on this site
Describe the proposed business including use, number of employe number of�shifts, available parkin spice number of
h Jets
vehicles, and any additional ipformati that can provide:
*This Clearance will only be vali 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 /' Printed "14 -1(A T-H A-0 Q0 AJ
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.
[ ] No physical site inspection has been done for this clearance. Therefore, it is not a determinafion of compliance with the existing
site plan.
[ ] This site complies with the site plan as of this date.
Notes:
-� ,
Building Official Date
CX
Zoning Official Date 1 � /;?6rZ,'_
�
Other Official Date
County of AIbemarle Department of Community Deveiopment
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
Revised 7/1/2011 Page 2 of 3
Intake to complete the following:
Is /
Is u LI, HI or PDIP tolling? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y /
Wil] re 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 or lie wat r?
If private well, provide Hea tb artment form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applie
Is parcel on septic or pu 'c sewer?
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y/N
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
7.nnina fn rmmnlPfP fhP fnllnwin4'
Reviewer to complete the following:
Square footage of Use: j
N I
iitted as: A4 L ti IM
Under Section: 22, 2'
Supplementary regulations section:
Parking formula::
Required spaces:
Y/N
Items to be verified in the field:
Inspector : Date:
Notes:
Violations:
(�
If s/ogist:
Proffe s:
Y /
If so, 1st:
Varian e:
Y
If so, 1st:
SP's:
Y/
If so, 1st:
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3
CERTIFICATION THAT NOTICE OF THE
APPLICATION HAS BEEN PROVIDED TO THE LANDOWNER
This forin 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 to
[County application name and number]
[name(s) of the record owners of the parcel]
and Par Number
manne 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].
ow
Signature of
T+i � T+/ ho ett 00.0c—
Print Applicant Name
C ov-) Bola
Date
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