HomeMy WebLinkAboutCLE201200062 Legacy Document 2012-04-021 Dft, h A T Ire p�
Application for Zoning Clearance
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PLEASE REVIEW ALL 3 SHEETS
Check #
Receipt #3HU= Staff:
PARCEL WORMA ION
45 (0
Existing Zonin
Tax Map and Parcel; „ ((03L /�tu�D?
Parcel Owner; i?D I°Jne 5 D't"' t U LC) rill. L�
Parcel Address; 315 FOUL l.etc Z4,'16 %Sfe-cityCharlo *iler y/lkte VA Zip+;'216
(include suite or floor) �p
PWATARY CONTACT /
aTl't l�j
Who should we call/write concerning this project? ,f M4617
Address ; . ;-345 EadgnfJ lle Ad E , City tt r tisyl7/9 1 state • VrA
Office Phone: Cell # Y,4YA gbis 'ax# �j4��96 ao7 -mail kadtuad���>��(n CUs
APPLICANT INFORMATION
Check any that apply: Change of ownership Change o€ use Change of name New business
Business Name/Type: Mouii S id e't. GC
Previous Business on this site yes /-6 dou � ee 1'r %7 eAn rl
Describe the proposed business including use, number of employ es, number of shifts, available parldng spaces, number of
l-
vehicles, and any additional information that you can provide: Sir ✓AY - rqka rf S/ e;)n W iM W01
ses 4 e rh. a s a r A r
¢ e..
• his Clear ce will only be valid on parcel for which it is approved. If you change, intensify or move the uso4b a new locat►oA 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 ceifify that the information provided
is true and accurate to the best} of my lmowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature �' "�J��1 Printc;kG�
P VAL INFORMATION
[ Approved as proposed [ ] Approved with conditions [ ] Denied,
] Backflow prevention device and/or current test data needed for this site. Contact ACSA, 977 -4511, xl l7.
[ ] 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.
Motes;.
Building Official Date a a.
Zoning Official 1:t72 , Date
Other official 1` > `�i Date 3 f a.-1 `1
UOUnty otAibemarie Department or L;ommumty 1/eveiopment
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296- 5832Fax: (434) 972 -4126
Revised 711/2011 Page 2 of 3
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Intake to complete the following:
Y/N
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y/N
Will there 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 ublic Ovate
If private well, provide Health epartment form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that apl5lies
Is parcel on septic or is sewe .
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 #
Zoninff to complete the followings:
Reviewer to complete t/he following:
Square footage of Use: / � g�
y/ / N 1
Permitted as:
Under Section:
Supplementary regulations section:
Parking formula:
Required spaces:
Y /1�I
Items to be verified in the field:
Inspector Date:
Notes:
Violations:
Y/ O
If so, List:
Proffers:
Y �rN
If sb; It:
Variance:
Y/
If so, ist:
SP's:
Y/N
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 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, ZoninA L X C2 an c- e -
W00116" [Coun application name and number]
was provided to Jx L4W>7 LLC the owner of record of Tax Map
[name(s5 o the record owners of the parcel]
and Parcel Number 556 F I ^ by delivering a copy of the application in the
manner ' entified below:
Hand delivering a copy of the application to ben orl f 0 wrin e ✓
[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- MM,k �0, 01 A
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]
M
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].
Signature of Applicant
h e
Prmt ApplicE6t Name A jpUA* Mx)' n C &,C
/tAr1k- AD, a a/,4-
Date