HomeMy WebLinkAboutCLE201500053 Application 2015-04-02Application for Zoning ClearanceJit1,.
CLE # ZO l S S 3 �`t_4 6 °'"�`
OFFICE USE ONLY
PLEASE REVIEW ALL 3 SHEETS Checic # 25 Date: 3 J J
Receipt # " r'� 2 Staff:
PARCEL INFORMATION
Tax Map and Parcel: / in 0—Odd _ P- � �y0� Existing Zoning
ParcelOwner:
Parcel Address: (o7l 6--a-aA Sk aQ I City 121166121k """ State (J/0' Zip
Qaqo
(include suite or floor)
PRIMARY CONTACT C(
Who should we call/write concerning this project?
Address: lkoq &s"/V& Or city lk-311 �Q�_ State [%fl ZiP G292�
Office Phone; (_� Cell # �;�(-i8'! 1 Fax # E-mail rlskn "4. �u G � ?%(U nla 1 » c
Kai sf env.4✓ a j
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name _New business
Business Name/Type: O2 �' �� ��}L� f7 AlfiL
J
Previous Business on this site n
Describe the proposed business including use, number of employees, number of shits, available parking spaces, number of
vehicles, and any additional information that you can provide: t f r'nQ Sct p S
*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 ave the owner pe mission use the space indicated on this application. I also certify that the information provided
is true and accur to the st of my knowle e. I hav/ ad the conditions of approval, and I understand tjhem, ]_and that I will abide by them.
Signature Printed rl s� ���L` /(U
APPROVAL INFORMATION Denied
>X] Approved as proposed [ ] Approved with conditions [ ]
[ ] 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 Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (434) 972-4126
Revised 7/1/2011 Page 2 of
M
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 /
Wil 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 Irublic wate .
If private well, provide HeaA He ment form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that app. ies--1
Is parcel on septic or public sewe
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Reviewer to complete the following:
Square footage of Use:���
O/N
Permitted as: 04GP. ( A 15(/
Under Section: • 1- -2.1
Supplementary regulations section:
Parking formula:
Required spaces:
Y/�
Items to be verified in the field:
Inspector:
Date:
Notes:
Y/N
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the following:
Vio tions:
Proffers:
Y/e)
Y /
If so, List:
If so, ist:
Vari ce:
Y/
SP's:
I o,Wist:
If s , ist:
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3
P
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;
[County application name and number]
was provided to the owner of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number
manner identified below:
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]
on
Date
to the following address:
[address; written notice mailed to the owner at the last known address of the owner as snown 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