HomeMy WebLinkAboutCLE201200063 Legacy Document 2012-04-04f�" moils,
Application for Zoning Clearance
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CLE # �0 Z t93
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OFFICE U ON Y -12
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PLEASE REVIEW ALL 3 SHEETS
Check # Date:
Receipt # Staff: J
PARCEL INFORMATION
1
Tax Map and Parcel: ( I U 0 — 2 — 00 00 Existing Zoning. i
Parcel Owner: ?�'e f_kMA r TGc
Parcel Address: 300 S Serk ngA i— �)r City CAA f 4gj7 ,, tate
(include suite or floor)
PRIMARY CONTACT
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Who should we call/write concerning this project? A L —Ex/A
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Address: i� -r-� i (—C V�G cr2 S�" Lt�1 City l,Otic 5 y� 112 State �/� Zi- /
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Office Phone: (4� $7 �_7 — yla Cell # Fax # E -mail a I Ua C • MA �n7S
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APPLICANT INFORMATION
Check any that apply: Change of use Change of name New business
/_ -.Change `ofd�ownership
Business Name/Type: A IXC yk44"�1 -et,25 fg J V�r_ Mk a-e. / MG 1;5: <7iVZt D
Previous Business on this site U
Describe the proposed business including use, number of employees, number of shifts, available parking spaces, number of
vehicles, and any additional information that you can provide:
P_rn (D S-i C' 5 Y! Z r-' CAM
I x -1 • G4'- + + ► LV ' x 5.5-F+ -h::, 5a ,t4 15
*This Clearance will only be valid on the parcel f which it is approved. If you change, intensify or 11vove 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 th at 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 9�� °` i��"c—V ` 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 „� �✓U Date H L�
Zoning Official ,t .. 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 orI
If private well, provide Heal eent form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that appli
Is parcel on septi or publ' er?
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 followine:
Reviewer to complete the following:
Square footage of Use: ablold 1/00 gs. P
I /N
ermitted as: ✓o-� , r �; QC,
Under Section: Z4,1-1
Supplementary regulations section:
Parking formula:
Required spaces; I,--
Y/
Items to be verified in the field:
Inspector • Date:
Notes:
Violations:
Y
If so, List:
Proffers:
Y/0
If so, List:
Variance:
Y/0
If so, List:
SP's:
Y/(it)
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, A C �o� 4�0 r 2-01;, C n L"-
[iCounty application name and numb r]
was provided to LL C-- the owner of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number 19(Q 1 U O -(-0- 00-300 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
Y Mailing a copy of the application to F>-9 HZ'-MA r G F--)L- Z-L—
[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:
3002 �e F" r , T C�l��le es►� II e, �//� 22 go/
[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
Print Applicant Name
3 -2a -/2
Date