HomeMy WebLinkAboutCLE201200061 Legacy Document 2012-04-04Application f ®r Zoning Clearance_
s
OFFICE U�E Y
PLEASE REVIEW ALL 3 SHEETS
Check # Date:
Staff: VYIX-U
Receipt #
PARCEL INFORMATION
Tax Map and Parcel: 0(.k l.lt`O ' Oa ' O O ` O%3 f 6 o Existing Zoning P7
Parcel Owner: AME-S PA f5 90A-)�0'1J
�/ `/ `' ^_
Parcel Address: -vy5`i b- V1 -r�pv N-% City ( Y�i JyL—_ State 10 l� Zip
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project?
Address: H 54 DOV1�1►- 1�i -�., � City i I 1 � State Zip 7-7-'Z
Office Phone: l( U ? q-ql- (,-Cell # 703 v5 07j ?Fax # E -mail Aj"q k e qiwit t'
APPLICANT INFORMATION
Check any that apply: Change of ownership. Change of use Change of name business
hfN�ew
A /�
✓ ��a L 'i r n, � \6, ' L
Business Name /Type: t 1" `V
Previous Business on this site vD✓'c YlA,:9A-1-=Q&= a
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: 3 (14,12 Ltv eC
*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 Printed JA-nn s 3L,.- vj
APPR VA INFORMATION
Approve 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 detenninafion of compliance with the existing
site plan.
[ ] This site complies with the site plan as of this date.
Notes:
Building Official Date �� m f
Zoning Official Date - 310116/2'
Other Official Date
County of Albemarle vepartment of t- ommumty 1ueveiulr►liell
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 us LI, HI or PDIP zoiung? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y / �N
Will ther 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 -public wat ?
If private well, provide Health De artini t 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 pdblic sewer ?„
Y/N
Will you be putting up a new sign of any kind?
Sign permit.
Permit #
If so, obtain proper
Jf / N
ill there be any new construction or renovations?
If so, obtain the proper Permit.
Permit # 7-6 /'Z
7.onin to P m lete the followin
Reviewer to complete the following:
Square footage of Use: / t ,&D
l N l r
ermitted as:
Under Section: � • 2—J
ir2 1
Supplementary regulations section:
Parking formula: /
Required spaces:
Y/N
Items to be verified in the field:
Inspector :
Notes:
Date:
Violations:
Y/ -N
If so, Dist:
Proffers:
soY% st:
If , i
Variance:
Y/
If so, List:
SP's \
Y /�Y
If so, List:
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3
n
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]
.:1
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
"Print Applicant Name
Date
I o
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