Loading...
HomeMy WebLinkAboutCLE201200080 Legacy Document 2012-04-24Application for Zonine Clearance CLE # OFFICE US ONLY 4-116- t2- PLEASE REVIEW ALL 3 SHEETS Check 4 1 to Date: Staff: YV 4 Receipt # PARCEL INFORMATION � T Tax Map and Parcel: 0 9100,0 _ o a -do- e � 5" 40 Existing Zoning Parcel Owner:, Parcel Address: t/ � 72 -S h 0 W jp 0 at L a- _ _ City a,4 /A Fes' 4 11P- State L' Zip Z 2 f 0 z- (include suite or floor) PRIMARY CONTACT Who should we call /write concerning this project? Address: 560 ye. S'ql& 360 City 6 ✓ 11e- State � Zip z�%° z /(/ Office 'hone: Cell# o- z 1:0x# e' - E -mail 4 / 14 Y7tl ul A/a J ec fe 34 APPLICANT INFORMATION Clieck any that apply: Change of ownership Change of use Change of ntirne -,-,,_Neiv business Business Name/Type: E e.0M h, a l e R. .d H ,e [] Previous Business on this site• lI z e.— . e ill e I t 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: d (2, *This Clearance will only be valid on the parcel for which it is.approved. Ifyou change, intensity or move the use to a new location, a new Zoning Clearance will be required. I hereby certify that I own or have the mNiices permission to use the space indicated on this application. I also certify that the infonnation 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 Swm CPC APYAOVAL INFORMATION [1 Approved as proposed [ a Approved with conditions [ ] Denied [ j Backflow prevention device and /or current test data needed for this site. Contact ACSA, 977 -4511, x117. [ j 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 Date e_ 1 Zoning Official Date �( a Other Official Date a:ounry o[ Arnemar•ic uepartmentofCommunity Development 401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296,5832 Fax: (434) 972 -4126 Revised 711 /2011 Page 2 of 3 fi A Intake to complete the following: Y6 Is use m LI, Hl or PDIP zoning? If so, give applicant a Certified :Engineer's Report (CER) packet. Y / Will ere 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 p lic water. If private well, provide Health 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 blic sewer? Y /0 Will you be putting up a new sign of any kind? If so, obtain proper Sign permit. Permit # 'ti0 se��� Y / NN �r ml 1 WiII`fhere be any new construction or renovations? If so, obtain the proper Permit. Permit # Zoning to complete the following: Reviewer to complete the following: /' Square footage of Use: 16 `I O V/ N Permitted as: (� 1 Under Section: Supplementary regulations section: Parking formula: ii �-8 hes �t Required spaces: Y/N Items to be verified in the field: / Inspector : Date: Notes: Violations: Y/N If so, List: Prof YI(N) If so, ist: Var an e: Y/N If so-,-gist: 's: /N Fr o, List: Clearances: SDP's I r��f q Revised 7/1/2011 Page 3 of 3 CERTIFICATION THAT NOTICE OF THE APPLICATION HAS BEEN PROVIDED TO THE LANDOWNER This jnrm must accompaly toning applications (Horne Occapation,.Zotring Clearance, Zoning Administrator Determinations or Appeals, Sign Permits, Bulltling Permits) if the application is not the o3vner. I certify that notice of the application, AlG"r (f b 144 *" U N IC A ' ° S l! L" C— [County application name and number] was provided to R D P � !t c- the owner of record of Tax Map [name(s) of the record owners of the parcel] and Parcel Number 40 �00 -06 M ©n + L� ff 00 by delivering a copy of the application in the manner identified below: ^^�� Hand delivering a copy of the application to a Am e 6-fic W [Name of the record owner if the record owner is a person; if the owner of record is an entity,. identify the recipient ofthe record and the recipient's title or office -for that entity.] on 4"1"" 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]. C-11 .l �.....� Si 1att p ant Print Applicant Name Date