HomeMy WebLinkAboutCLE201500092 Application 2015-05-21Applicata®n f®r Z®ning Clearance�,«�-
CLE # 9,0� s -aa
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OFFICE U LY j
PLEASE REVIEW ALL 3 SLEETS
Check # Date: r
Receipt # Staff-
PARCEL INFORMATION
Tax Map and Parcel: (074-60 - GO .- Q®- (946 40 Existing Zoning T
T r c
Parcel Owner: dt� JJ \-,-cck--
Parcel Address:( �i i�`�cw a City QU� &ail State iy� Zip Z (�
(include suite or oor)
PRIMARY CONTACT `
Who should we call/write concerning this project?
Address: 1� ; �; f ; A �,City kCQt✓W2 State Zip —'71'FQb
Office Phone: (41!0 4f6(o- 9'6)&3 Cell # Fax # E-mail L�t;�
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use —Change of name New business
j(
Business Name/Type: b—y\
Previous Business on this site kc-�T �r.C.
Describe the proposed business including use, number of employees, num er of shifts, available p rking spaces, number of
vehicles, and any additional information that you can pr vide:'' i-'ev � •X-i�t % �P
JAL:, G 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 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 o est o my knowledge. I have read the conditions of approval, nd 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 A Date .K Z) -e (( )-
Zoning Official Date I r/�.1/2�,V
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 3
Intake to complete the following:
()/ N
Is use in LI, HI or PDIP zoning?
Engineer's Report (CER) packet.
If so, give applicant a Certified
Y /
Will 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 wel atphD
ter?
If private well, provide ea ent form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applies
Is parcel on septic �
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y/N
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zonine to complete the following:
Reviewer to complete the following:
Square footage of Use: /1 3 V 5
I/ N p
ermitted as: ' " 6
Under Section: Z L ,2 •�
Supplementary regulations section:
Parking formula:
Requir d spaces:
Y/ Fj
Items to be verified in the field:
Inspector : Date:
Notes:
Violations:
Y/P
If so, ist:
Prof rs:
Y/
If so,List:
Varig ce:
Y/CN)
If so, List:
its:
/N
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,t��o�
r
[County application name and number]
was provided to E vv� '(� j -K C- the owner of record of Tax Map
[name(s) of the re rd owners of the parcel]
and Parcel Number 0 1:22LO 014 C9 by delivering a copy of the application in the
manner identified below:
9 t
Hand delivering a copy of the application to tit' 5j V✓4'j t�cr.�-�-L�G���r`,�/ ,•�C�, c�
[Name of the fecord owner if the fecord owne� a
person; if the owner of record is an entity, identify the recipient of the record and the recipient's
title or offic fo that entity]
on
Datel
�Q Mailing a copy of the application to V kS O� i,�; "Cf�t,:`c.L-! .�•�t C-�
[Name of the record owner if the record owner is a person;
if the owner of record i s an entity, identify the reci pi ent of the record and the reci pi ent's titl a or
office for that entity]
on to the following address:
Datet
[address; written notice mailed to the owner at the last1known address of the owner as shown on
the current real estate tax assessment books or current real estate tax assessment records satisfies
this requirement].
Print Applicant Name
Date
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