HomeMy WebLinkAboutCLE201200095 Legacy Document 2012-04-30Application for Zoning Clearance
CLE # ZZb 2 — 015
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PLEASE REVIEW ALL 3 SHEETS
OFFICE USE ON W
Check # 2 L Date: `2� i2
Receipt # Staff:
PARCEL INFORMATION C ( ✓
Tax Map and Parcel: O% i w t —02--c)4-0000 Existing Zoning
Parcel Owner: aa 4 LA-0. �0
V
Parcel Address: AW n( C t ?—City /k
k, State VA- Zip 2Z401
(include suite or floor)
PRIMARY CONTACT "bl�61e
Who should we callll /writ'e this project? Tr'
"concernin`�g ,
Address: (S�� TKC,fWVA.4g00 City �VlGts State Ix Zip z
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Office Phone: &6I) J?JJ Cell # --- Fax # S && , d - ak -mail ��eh �Z �@ P+' fY►� t d /�
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
n -
Business Name /Type: 11(I MI �� A 'Yllltiwo ��
Previous Business on this site LtM.11AMCl
Describe the proposed business including use, number of employees, � �n�um,,ber of shifts, available parking spaces, number of
vehicles, and any additional information that you can provide: l .4- - I t� 4.1 ( Lf
*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 o the be of my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
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 determination of compliance with the existing
site plan.
[ ] This site complies with the site plan as of this date.
Notes:
Building Official Date
Zoning Official Date
Other Official Date
County of Albemarle Department of Community lievelopment
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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Intake to complete the following:
Y/N
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y/N
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 o ublic water
If private well, provide Heal nt form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that a
Is parcel on septic ors lic sewer
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y/N
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
7,nninu to comnlete the following:
Reviewer to complete the following:
Square footage of Use: ,z iii%
/N I
ermitted as: 40 n i,—y!; i a 7N4-.
Under Section: 'r2. Z ,'
Supplementary regulations section:
Parking formula:
Req ' ed spaces:
Y/'
Itdhfto be verified in the field:
Inspector : Date:
Notes:
Vi ons:
Y'V
If so, List:
Prof rs:
Y /
If so, List:
Var�ia�nce:
Yt )
If s , ist:
SP' '
Z'/
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, (A"Vt k af, MW ..VtiV.,W
[C my pplication name and number)
was provided to V f&t the owner of record of Tax Map
[name (4) of the record owners of the parcel]
and Parcel Number () tp I W I — 0" * —DO 10 D by delivering a copy of the application in the
manner identified below:
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 J&vw L, oa-,T , V aA W-, W .
[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 A-11yi 12 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].
Uy �'
Sign tune of awoc Ap licant
-Kr I41
Print Applicant Name
A [ M a-
Date