HomeMy WebLinkAboutCLE201500063 Application 2015-04-209
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Application for Zoning Clearance��
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OFFICE UJE ON Y J,rl
PLEASE REVIEW ALL 3 SHEETS Check # Date:
Receipt # �71 a Staff: /
PARCEL INFORMATION rde_gti� c4 L -1 A ; 19 , 5-" 1
Tax Map and Parcel: 2130-5-como-oA`R eaf A__`�>'f' Existing Zoning
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Parcel Owner: []�
v����M.rtovtiw�ca�iie Ct�t��fd �6�i'S'tic��r StateVA
ZipZZ7v�
Parcel Address: y
(include suite or floor)
PRIMARY CONTACT /�ff/�J
Who should we call/write concerning this project? /'l,�fi� y7-0
V tG State (64 Zip 7-Z-907-
Address:
L9OZAddress: 6%/S0Ae-e_-oA City
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Office Phone:
y� �� OD'Ze% Cell A2� _9) %S® Fax # E-mail 17J a4zJC • 1-
APPLICANT INFORMATION
Check any that apply: CChange of ownership r0h-angeof use
Business Name/Type: 1! /K �� ?��F;
Previous Business on this site %f Or " ke U " "'� Ll
V, 4Gt7t'10,
Describe the proposed business including use, number of employees, number
vehj,ples, and any additional information that you can provide:�L�
*This Clearance will only be valid on the par el for which it is approved. If you
Clearance will be required,
Change of name
sale r p
S�F
of shifts, available parkin
4CC'
a2✓ irlhm
ten,fify or move the use to a ri
V New business
%e-aw o
g spaces number of
L,
m location, anew Zoning
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 to the best 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 `�~ o r-.� t Date i� t
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/l/201 1 Page 2 of/3
I
Intake to complete the following:
Y/cwj
Is use in LI, M 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 ot( , ublicwat ?
If private well, provide Health-Depa ment form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that app �es
Is parcel on septic or ublic sewer?
Y / N
Will you be putting up
a new sign of any kind? If so, obtain proper
Sign permit. 2
Permit #
Zoning to complete the foll owing:
Reviewer to complete the following:
Square footage of Use: S,I-
i' / N ) (}
Permitted as: ed) e -A
Under Section: ,2 '
Supplementary regulations section:
Parking formula: J
2J D
Required spaces:
Y/
Items to be verified in the field:
Inspector:
Date:
Y /�th.or'
Wil e be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Notes:
Zoning to complete the foll owing:
Violations:
Y
If so, /ist:
Proffers:
Y/
If so, List:
Variance:
Y/
If so,st:
SP's:
Y/
If so, List:
Clearances:
SDP's
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
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]
/9
was provided to 6 Q-[ 1err`n (!- � a r i S k, _ the owner of record of Tax Map
[name(s) of the record owners of the parcel]
Z305- �tk lbr-
and Parcel Number (9 1.,1 W o > 01--b&—Q6&00 by delivering a copy of the application in the
manner ' entified below:
AV
/� ��rr __ P
-1 Hand delivering a copy of the application to ( Ae CsD r�S
[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 L/ l
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].
S gnature of Applicant
i•int Applicant Name
1 11/4 `rs'
ate
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