HomeMy WebLinkAboutCLE201200069 Legacy Document 2012-04-12Application for ZoIllillia Clearance
CLE #
PLEASE REVIEW ALL 3 SHEETS
OFFICE USAF ONLY
Check # ` � �J Date:
Receipt # aE 2M Staff:
PARCEL INFORMATION
Tax Map and Parcel: $ Existing Zoning
Parcel Owner: Almo an,
/
6FV � � Zip
Parcel Address: City ( State
(include suit or floor)
PRIMARY CONTACT ` \
`Q T
Who should we call /write concerning this project? :,
Address : 'c�. a\A"� City `j d State Zip as �r� l
Office Phone: (qbt}) QZ C1 " Q 14I Cell #( yl �koq _ 1'73 3 Fax u� 4��i� jq� E-mail Q CC h
APPLICANT INFORMATION
Check any that apply: Change of ownership. Change of use Change of name New business
Business Name /Type: lr-Lllcl
�V
-\ bn
Previous Business on this site
Describe the proposed business including use, number of employees, number of shiftsp a i bI rking spaces, n ber)gf .
�
vehicles, and any additional information that you can provide: C °f �/Y1a�/ i /)CiLYi /Y
*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 s permission to the space indicated on this application. I also certify that the information provided
is true and accu to the best of my wledge. I have read the onditions of approval, and I understand them and hat I will abide by them.
Signature 406 A
APPROVAL INFORMATION
Q Approved as proposed [ ] Approved with conditions [ ]Denied
[ ] Bacicflow 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 detennination of compliance with the existing
site plan.
[ ) This site complies with the site plan as of this date.
Notes:
Building Official �— Date L-( 1 �'
.Zoning Official Date Z h1i 7, v l-71
Other Official Date
County of Albemarle Department of uommumty meveiopment
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
Revised 7/1/2011 Page 2 of 3
r�
Intake to complete the following:
Y /
Is use n LI, HI or PDIP zoiung? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y /(f�)
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 or
If ?
If private well, provide Healt u 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 p i 'c sewe .
Y/N
Will you be putting up a new sign of any kind?
Sign permit.
Permit #
If so, obtain proper
Y/N
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
7.nnina to rmmnlpfp fhp. fallowing.-
Reviewer to complete the following:
Square footage of Use:
/ N
Permitted as:
Under Section: fL• Z,
Supplementary regulations section:
Parking formula:
Jo
Required spaces:
Y/N
Items to be verified in the field:
Inspector
Notes:
Date:
Violations:
Y/&
If so, List:
Proffers:
Y /(�>
If so, List:
Variance:
Y /.N)
If so, List:
SP's:
Y/N
If so, List: r,
�S -7 -- -73
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.
1 certify that notice of the application, 4O
[County appli tion name and number]
was provided to Z0.rnen I Vt'?i7iy)p& 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 To yy m h no n Il
[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]
•m
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
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
L-V� T"� ,
"Print Applicant Name
Date