HomeMy WebLinkAboutCLE201200067 Legacy Document 2012-04-04Application f ®r Zoning Clearance
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PLEASE REVIEW ALL 3 SHEETS
OFFICE USE ON
Check # 3-535 5 Date: � ' Z A
Receipt # Staff:
PARCEL INFORMATION
Parcel: Il Y a Existing Zoning %V Vv4 ('Q ss'
Tax Map and
Parcel Owner:
Parcel Address: Z3/— Qo-ng City Svi l State V k Zip
(include suite or floor)
PRIMARY CONTACT t
Who should we call/write concerning this project?
o�a-�— City L 1I�9t W u� State QF� Zip 0c�ll l
Address : 1���W1��
Office Phone: Cell # Fax # Y3t(- T8'f- 3576E -mail P C (-0 Q '(A' �it\ K .
APPLICANT INFORMATION
Check any that apply: Change of ownership, of use Change of name New business
1Change
Business Name /Type: 'V-)Q
Previous Business on this site
Describe the proposed business including use, number of employees � - number of shifts, vailable parking spaces, number of
vehicles, and any additional information that you can provide:
*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 o 'er's permission to use the space indicated on this application. I also certify that the information provided
is true and accurate t t Y m nowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature Printed
- V
i
APPRO AL NFORMATION
�FI Approved as proposed [ ] Approved with conditions [ ] Denied
] Backfiow 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 an.
[ vf This site complies with the site plan as of this date,
Notes:
Iiuildin Official �-�, Date . F-
g 1
Zoning Official Date �Ao/ 2—
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
n+
Intake to complete the following:
Y /l.:/
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y
Will 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 blic water9
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 applie
Is parcel on septic ublic sewer
Y/N
Will you be putting up a new sign of any kind?
Sign C
Permit
#
Reviewer to complete the following:
Square footage of Use: _ _ 3-706
-V/ N ((��
Permitted as; -y"(, i -qAiUAl 28v34
Under Section: ' --7 '' (h 5l
Supplementary regulations section:
Parking formula:
Required spaces: 2L -/
It , '--
Ite e verified in the field:
If so, obtain proper
Inspector : Date:
Y / N Notes:
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
7nninu to complete the following:
Violations:
N
f so, List; II L '�
Proffers:
If/oi
If so, ist:
Varia e:
Y
If so, ist:
SP's:
Y/
If so, lst:
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,
was provided to
[County application name and number]
[name(s) of the record owners of the parcel]
and Parcel Number
manner identified below:
the owner of record of Tax Map
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]
.._
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]
..
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].
i a of Applicant
Print Applicant Name
Date