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HomeMy WebLinkAboutCLE201200089 Legacy Document 2012-04-27Application for Zoning Clearance OFFICE USE O V 1 b `23.1 Z PLEASE REVIEW ALL 3 SHEETS Check # Date: Receipt # Staff. PARCEL INFORMATION p b - 6 '�� ®� '" V � 3 0 0 Existing Zoning Tax Map and Parcel: °� /� -` - Parcel Owner: C� `Zq�` j'// :E� -e_C5 , L C q'�*-F111©Eity 6(9 t;0-0 CO-7,&-t �V �q3 Parcel Address: , State Zip (include suite or floor) PRIMARY CONTACT Who should we call /write concerning this project? Address: Ooq 44H M6 � x" y,, ELK , City State y A Zip X0 01-0 Office Phone: - �b — 6'Z `i Cell # �3� -a �'� ©7iFax # `f 3 f ��I E -mail lava 619 dp /54 , ��. APPLICANT INFORMATION Check any that apply: Change ofpownership Change of use Change of name New business (� , 1 P I U ('Al l 4'IIU � Business Name/Type: (' I [ Previous Business on this site t� Describe the proposed business including use, number of employees, number of shifts, avail ble parking spaces, number of vehicles, and any, addit'ona information tha you can provide: i r ?/ S -�1'UL>° V -c J V- � fi n' *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 knowledg I ha e read the conditions of approval, and I understand them, and that I will abide by them. I—Aym Signature( Printed E Co A. VAT, INFORMATION Ypproved 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 c _ Date 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 (3 11 } f Lf L-11 0 O-VI Cn -zt4- V A- 3 21- W'LL +01-4t 5� (3 i f -7 -e ,,-o 0 tl-\, 3 4 bt ins tJ 4.r- Jv+eeL-A\ S-�-Z," vie -(,D stvl,i-b-Y- �,-(` V-1 rc--s,,-J Intake to complete the following: Reviewer to complete the following: Y Square footage of Use: (`� Is us m LI, HI or PDIP zoning? If so, give applicant a Certified (err:tted Engineer's Report (CER) packet. / as: r Will re be food preparation? Under Section: - . ( jj ® UJ 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 Circle the one that applies ?. Is parcel on private well or public water? If private well, provide Health Department form. Zoning review can not begin until we receive approval from Health Dept. FAX DATE Circle the one that applies 7 Is parcel on septic or public sewer? Y/0 Will you be putting up a new sign of any kind? If so, obtain proper Sign permit. Permit # Y / Wil(tere be any new construction or renovations? If so, obtain the proper Permit. Permit # Zoning to complete the following: Parking formula: ,OCo Required spaces: Y/N Item be verified in the field: Inspector : Date: Notes: Violations: Y/N If so, List: Proffers: Y/N If so, List: Variance: Y/N If so, List: SP's: Y/N If so, List: Clearances: SDP's �117i� f 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, LC.Y�?.t�x�t,�N. /� p [County application name and number] was provided to (.�CO llei4 par+AY -- , �— �— C the owner of record of Tax Map [name(s) of the record owners of the parcel] and Parcel Number OS- b 0 0630()by delivering a copy of the application in the manner identified below: r _ / 0- . a � l�Y�t'�`,Q Hand delivering a copy of the application to Cke-r" " 5O e—r — CO D A [Name A 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 If ( 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 F, C6-a,,,, Print Applicant Name L( I )L-0 /i -)- Date