HomeMy WebLinkAboutCLE201500072 Application 2015-05-04Application for Zoning Clearance
CLE # 'oZU�S' 1a
OFFICE USE ONLY
PLEASE REVIEW ALL 3 SHEETS Check # 1019 Date:
Receipt # q Q t'1 LA b- Staff: �
PARCEL INFORMATION
Tax Map and Parcel:
Parcel Owner:
L t- cl
Existing Zoning W C
Parcel Address: �I City State
(include suite or floor) i A
V A • ZipZ?q /1
PRIMARY CONTACT kr_
Who should we call/write concerning this projects 0
Address:
City1, D Zi
e State A . p
Office Phone: (� �7Q' ZT l Cell # X31 — (11D Fax # E-mail
7' X31-0516 -
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name ew business
Business Name/Type:
Previous Business on t
Describe the proposed business including use, number of employ s num r hifts, available parking spaces, n✓u"Per of
vehic s, and any additional information you can p�ovide.2
*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 ow or ave the o ner's permission to use the space indicated on this application. I also certify that the information provided
is true and accuratei
e be of my owledge. I ave read the conditions of approval, and I` deerstand thend that I will abide by them.
Signature �.Printed
APPROVAL INFORMATION I
><] 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 f .\
:::Zoning Official Dated
Othel• 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
Intake to complete the following:
Reviewer to complete the following:
Y / Q
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified\
So
Square footage of Use: o
Engineer's Report (CER) packet.
\
Y/6)
Will there be food preparation?
j�' / N
.�� Y�t
ermitted as: ���q✓"aT r��
)
Under Section: -/
If so, give applicant a Health Department form.
Zoning review can not begin until we receive approval from Health
Supplementary regulations section:
Dept, FAX DATE
Circle the one t lies
Is parcel on 'E!yjRwell or public water?
If private well, provide Health Department form.
Zoning review can not begin until we receive approval from Health
Parking formula:
yn�
Required spaces:
Dept. FAX DATE
Y/N
Circle the one that applies
Is parcel ot11�2 or public sewer?
Items to be verified in the field:
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Clearances:
Sign permit.
Permit #
Inspector : Date:
Y/N
Will there be any new construction or renovations?
Notes:
If so, obtain the proper Permit,
Permit #
Revised 7/1/2011 Page 3 of 3
ZoninLy to complete the following:
Violations:
Y/
/
If so`� ist:
Proffers:
N
so, List:
nce:
Vari(N�
Y /
so,ist.
SP's
Y(N JIf
If so`List:
Clearances:
SDP's
63-21
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]
was provided to r' the owner of record of Tax Map
[name(s) of th record owners of the parcel]
and Parcel Number by delivering a copy of the application in the
manner identified below:
V/Hand delivering a copy of the application to AA I0^
[Name of the record o er 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 0
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 to the following address:
Date
[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].
Print Applicant Name
Date
., L
d
/Y
N