HomeMy WebLinkAboutCLE201200052 Legacy Document 2012-04-04Qt I
Application for Zoning - Clear-ance--- - - - - --
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OFFICE O LY
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PLEASE REVIEW ALL 3 SHEETS
Check # Date:
Receipt # Staff:
PARCEL INFORMATIOY. _
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Tax Map and Parcel: LP t Existing Zoning
Parcel Owner: J< m✓ PmVV-�W '1L
Parcel Address: 1 l Sc aotw w City co.� 1�i (Mate a%, Zip a 1 O
(include suite or floor)
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PRIMARY-- CONTACT - - — - - ` -
Who should we call /write concerning this project? 9 1'_q , I � b U/
City JUkt1 Mate Zip 3
Address: old 9 wl —4 %1I
Office Phone: (_) Cell # +�(+^831'707 -Fax # E -mail S 2 `
APPLICANT INFORMATION
Check any that apply: Change of ownership. Change of use Change of name New business
Business Name /Type: 3q Aim_ &e2cdi f' c AAJ �� slk�
Previous Business on this site am U-) D W4 ;0
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:
-
*This Clearance will only '6e valid in the parcollfor 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 be t of my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
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Signature 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 detenninafion of compliance with the existing
site plan.
[ ] This site complies with the site plan as of this date.
Notes:
Building Official Date 1 b 11
Zoning Official 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
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61
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Intake to complete the following:- - - - - -- -
Reviewer to complete the following;_
Y fn
Square footage of Use: -g5- v C
Is un LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y
Will / ere be food preparation?
4V / N
Permitted as: 444 tip . ; `/1'
Under Section: -2-� •�•
If so, give applicant a Health Department form.
Zoning review can not begin until we receive approval from Health
Supplementary regulations section:
Dept. FAX DATE
Variance:
Y/
If so, rst:
Circle the one that applies
Is parcel on private well or nrlA er?
Parking formula:
e , f Z�� l
Required spaces: - -
If private well, provide He th D ptent form,
Zoning review can not begin until we receive approval from Health-
Dept. FAX DATE
Y/
Circle the one that applies
Is parcel on septic,or ublic se
Items to be verified in the field:
Y/N
SDP's
Will you be putting up a new sign of any hind? If so, obtain proper
-
Sign permit.
Permit #
Inspector : Date:
Y / N
Notes:
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
7n„inrr fn nmm"la+n fhc fnUnwinm
Viiolations:
N
If so, List: / 1
Proffers:
Y /0
If so, List:
Variance:
Y/
If so, rst:
SP's:
If so�ist:
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3
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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,
[County application name and number]
was provided to the owner of record of Tax Map
- - - - names of the record owners of the parcel]
and Parcel Number
manner identified below:
and 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]
by delivering a copy of the application in the
on
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]
on to the following address:
Date
[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
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