HomeMy WebLinkAboutCLE201200120 Legacy Document 2012-05-29Application for Zoning Clearances..,
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CLE
OFFICE USYIN 5 �2�. Z
Date:
PLEASE REVIEW ALL 3 SHEETS
Check #
Receipt # Staff:
PARCEL INFORMATION ����1��� -E
Tax Map and Parcel: p/l I Existing Zoning
Parcel Owner: h •2 �rl� -S E'1_ w6 6�aAOA , Lj^Y_ ' `# ' 3.5v
Address: 3-75" 5" hou!- Lg. 4n -xr S�'� City C✓1 `b •'� tate Zip 22 103
Parcel
(include suite or floor)
PRIMARY CONTACT
��
Who should we call /write concerning this project? d
1 City ry Z State Zip
Address: U
Office Phone: CeII# XV -12a Fax # E -mail I—CiEh'014i
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
n L
Business Name /Type: ,e 1 ('-
Previous Business on this site a'a b_
Describe the proposed business including use, number of employees, number of shifts, available parking spa, number of
vehicles, and any adds Tonal information t t yoq, can provide: ja '
*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 th n o ve the owner's permission to use the space indicated on this application. I also certify that the information provided
is true and accur a the st of my know] ge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature I- Printed tel el QJ'1
V
APPROVAL INFORMATION
�
'1 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`1� I
Zoning Official A All Date
Other Official Date
County of Albemarle Department of community veveiopment
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
Revised 7/l/2011 Page 2 of 3
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 /
Will rilere 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 is wate
If private well, provide Healt ment 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 ublic sewe ?
Y/N
Wi ou be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y /
Will`{�ere be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
7.,.,;,,.r +n nmmnla +a +ha fnllnwinv-
Reviewer to complete the followings:
Square footage of Use: AP P I-61K
Pern:�tted as: , N j nieJ6 o-W) �
Under Section:
Supplementary regulations section:
Parking formula: /
Required spaces:
Y/N
Items to be verified in the field:
Inspector : Date:
Notes:
uvaalll VV �.vaaa
Viola ons:
Y/V
If so, List:
�P•,r\offers:
Y/N
If so, List:
Varia ce:
Y /
If so, ist:
SP's:
Y/N
If so, List:
Clearances:
SDP's J
Revised 7/1/2011 Page 3 of 3
0
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
anner identified below
the owner of record of Tax Map
by delivering a copy of the application in the
m
Hand delivering a copy of the application to Jame ✓l(J'^ �'w� ,�
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]
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
Print Applicant Name
Date
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