HomeMy WebLinkAboutCLE201500109 Application 2015-06-01tl1' .11.11f,l'
Application for Zoning Clearance
CLE #
OFFICE USE Q LY
PLEASE REVIEW ALL 3 SHEETS Checic # �°G`'j Date:
Receipt# Staff: fASdZ
PARCEL INFORMATION j� i 1
Tax Map and Parcel: (�� 1 - t Existing Zoning
Parcel Owner:�^� Co
5 t �% 17� ��
Parcel Address: S�h�p_� city C U State Zip ��
(include suite or oor)
PRIMARY CONTACT VV\ S�
Who should wne call/write concerning this AV \project?
n \ \
Address : -Ig `, �V�4lG1 I 3 City 1""( e-' State ) A Zip
yy�� . 1p 61 /� 4x #� 3 63D) E-mail
Office Phone:l(� Cell # 1 _
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of -name New business
Business Name/Type: ��G��e- S L l U
Previous Business on this site
Describe the proposed business including use, number of employe umber of shifts, available parking paces, number of
vehicles, and any additional information that you can provide:
*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 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 Denied
Approved as proposed [ ] Approved with conditions [ ]
] Backflow prevention device and/or current test data needed for this site. Contact ACSA, 977-4511, xl 17.
[ ] 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 �rNN 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
Intake to complete the following:
Y/
Is use i LI, H] or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y /M
Will Mere 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 applij:alt:h]
Is parcel on private we�,rtmRent
r?
If private well, provide form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that appli�
Is parcel on septic or ublic sew
Reviewer to complete the following:
Square footage of Use:
Q)/ N (�
Permitted as:
Under Section:
Supplementary regulations section:
Parking formula: /
Required spaces:
Y
Items to be verified in the field:
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Inspector : Date:
Permit #
Notes:
Y/N
Will there be any new construction or renovations?
If so, obtain the proper Permit,
Permit #
Zoning to complete the following'.
Violations:
Proffers:
Y /
Y
ist:
Ifs ist:
If
Vari e:
1'/N
SP's:
Y/
If so, ist:
If so, est:
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3
CERTIFICATION THAT NOTICE OF THE
APPLICATION HAS BEEN PROVIDED TO THE LANDOWNER
Thisform must accompany zoning applications (Home Occupation, Zoning Clearance, Zoning
Administrator Determinations or Appeals, Sign Permits, Building Permits) if the application is not the
n►vner.
1 certify that notice of the application,
[County application name and number]
was provided to V 6 LCIvJ C-0 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
V Hand delivering a copy of the application to A �--C� Q O
[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 shown on
the current real estate tax assessment books or current real estate tax assessment records satisfies
this requirement].
Sin tune of Applicant
Print Applicant Name
Date