HomeMy WebLinkAboutCLE201200071 Legacy Document 2012-04-04TJ11 Sul e)c
Application for Zoning Clearance
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CLE # 2b�.2
PLEASE REVIEW ALL 3 SHEETS
OFFICE USE ONLY
Check # Z.116� Date:
Receipt # v O Staff: ➢CCi
PARCEL INFORMATION
Tax Map and Parcel: 010000 - 00-406- 048A0 Existing Zoning C.orcVnw+C.Ccio., o�r�tca.
Parcel Owner: Qt.Amr r u L I-C.
Parcel Address: Z li 10 O\A!v� nQXA _S143MCity CA-,d r\6he -S A\¢.. State Zip ZZgo3
(include suite or floor)
PRIMARY CONTACT `
��yy%gv 7Ci. LnAai ffc1w1w�\Stt Scw
Who should we call /write concerning this project? t,.t �c.,C OVA
HxizA� Solnv�so�n -i�nC - \% 3.&I-«.}0m:�
Address: 155 S!ev �hq Siy":� . 6 -rJ City T,J&xZ'I oOe- State VVt Zip 10012.
Office Phone: ( -) 3�8-1'S`� 1 Cell # Qi 1, Z66 8380Fax # 7-12.:`U6161 61 -mail �•oa�Y�t��- o^%au�Q�:o�v�so�n.
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APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name X New business
Business Name /Type: 'Axa.1 \Aea\ v;%g, C.g a� v.vk
Previous Business on this site NOV\�2
Describe the proposed business including use, number of employees, number of shifts, available parking spaces, number o
vehicles, and any additional information that you can provide: f� i4_0_ �b'r PtsS�C
L' ' o �, ho zM\�V
*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 ► :�0.Printed
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 determination of compliance with the existing
site plan.
[ ] This site complies with the site plan as of this date.
Notes:
Building Official Date ( h
Zoning Official �,.� . x�7 /�1� .J+- Date
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
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,,, r public wate .
If private well, provide Health Dep ent form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applies
Is parcel on septic or". ublic 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 #
Zoning, to comDlete the following:
Reviewer to complete the following:
Square footage of Use: 9 t1
/N
Permitted as: C,.,e ,) In_
Under Section: 2�-•
Supplementary regulations section:
Parking formula:
Required spaces:
J
Y �
Item/ ! s the verified in the field:
Inspector : Date:
Notes:
Viol'af ons:
Y
If so, ist:
Proffers:
Y /N�
If so' st:
Vari ce:
Y/
If so, List:
SP's:
Y/A
If so", -List:
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3
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CERTIFICATION THAT NO'T'ICE OF THE
APPLICATION HAS BEEN PROVIDED TO THE LANDOWNER
This form must accompany zoning applications (Horne 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, Vvx,_\ CLE ZO\ 2-- b 5
[County application name and number]
was provided to '$j4� zV gsoy-,. Qv pxy L -L-C- the owner of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number
manner identified below:
by delivering a copy of the application in the
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
Xe 3b a copy of the application to 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 Mac e.kn Zz , Z,o \ Z. to the following address:
Date
\sez
[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]. v ZZn U3
signature of Appli
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Print Applicant Name
Date