HomeMy WebLinkAboutCLE201500059 Application 2015-04-09Application for Zoning Clearance`,,_''
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CLE #
OFFICE USE ONLY
PLEASE REVIEW ALL 3 SHEETS
Check # 12% 3 Date:
Receipt # Staff:
PARCEL INFORMATION 1 /q NmD
Tax Map and Parcel: 6 (/ W U ` 63'- U O'' U 'A Existing Zoning
Owner: %
Parcel )nO o{`okS rn
City �� ��Ste Zi
Paz-eel Address: Oi���il
(include suite or floor - / '
(C,(,
PRIMARY CONTACT
Who should we call/write concerning this project? Nx,
i
Address : ��� �� City I �l ate V79_ ZiP
Office Phone* � Cell # ` D6 — Fax # E-mail e (f.l
� (0S-3o�5 .
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Name/Type:
Business
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 infor atio�pthat you can provide:
t /
*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 or have the owner's permission to use the space indicated on this application. I also certify that the information provided
I them, and that I will ide by them.
is true and accu to the best of knowledge. I h ead the conditions of approval, and understand
Signatur Printed
APPROVAL INFORMATION
[ ]Denied
] 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,
N otes:
�- Date �-
Building Official
Date
Zoning Official
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
Intake to complete the following:
Y/0
Is u in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y/ON
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 appli01thpartment
Is parcel on private welwater?
If private well, provide form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that plies
Is parcel on septic 1 public sew ?
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
(9/ N
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit # -4C�
Reviewer to complete the following:
Square footage of Use:
(0/N
Permitted as: VA21,el
Under Section: 44fl/ Ace- 4-`2
Supplementary regulations section:
Parking formula:
Required spaces:
Y/N
Items to be verified in the field:
Inspector :
Notes:
Date:
Zoning to complete the following:
Violations: offers:
Y/Qst: /N
If sof so, List:
01 7
xariance: SP's:
WIN Y N
If so, List: If so, ist:
Clearances: SDP's 5,bp � —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
A(iniinistrator Determinations or Appeals, Sign Permits, Building Permits) if the application is not the
o wn er.
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: f� �
Hand deliveringa copy of the application toAJ
[Name of the record owner if the reco d 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]
by delivering a copy of the application in the
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].
AiggAureApplicant
Tint pp • ant Name
's
Date