HomeMy WebLinkAboutCLE201200093 Legacy Document 2012-04-30Application for Zoning Clearance
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PLEASE REVIEW ALL 3 SHEETS
Check # Date: —
Receipt # Staff:
PARCEL INFORMATI N �, j (� Gi `�If
��' ° Existing Zoning �� I lye Cd
Tax Map and Parcel: VU i'1 �–YV
Parcel Owner: CW
Parcel Address: 5 SeVAI `&I I Y'_ City z k-Akstate � Zip72010
(include suite or floor) "B!q_tv` ,
PRIMARY CONTACT
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Who should we call/write concerning this project.
Address) 5CO 6n1-AilwK'U City _ State ly� Zip2�
3172__ Cell 4 Xf SSt $3M Fax # 13'k 2125 E -mail W146 – 99ftiC�A�
Office Phone: MZ
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name /Type: �� kk
Previous Business on this site
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: 497
DAXES 1` 0
*This Clearance will only be valid on the parcel for which it is approve J. Ii you change- or move the use to a new location, 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 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.
and
Signature _ Printed O1(1
APPROVAL INFORMATION
>] Approved as proposed [ ] Approved with conditions [ ] Denied
[ ] Backflow prevention device and/or current test data needed for this site. Contact ACSA, 477 -4511, xl 17.
[ ] 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 1
Zoning Official ` Date
Other Official Date
County of Albemarle Department of community Deveiopmenr
401 McIntire Road Charlottesville, `TA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
Revised 7/1/2011 Page 2 of 3
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Intake to complete the following: Reviewer to complete the following:
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Y / NT Square footage of Use: ^ S
Is use in LI, III or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet. Y' / N
Permitted as:
Y
Will ere be food preparation? Under Section:
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 varicing rormuia:
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 Required spaces:
Dept. FAX DATE
Y/N
Circle the one that applies Items to be verified in the field:
Is parcel on septic or public sewer?
�Y /N
Till. you be putting up a new sign of any kind? If so, obtain proper
Sig
Permit # n permit.
Inspector: Date:
Y Notes:
Will ere be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
A1%J H IL
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
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,
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]
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]
•.
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
P1`rii- k nt Applicant
t n/4 r1I'V, V
Date
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