HomeMy WebLinkAboutCLE201500074 Application 2015-06-0505/15/2015 15:49 4349854822
Greene County VDH
#1942 P.002/002
Application for Zo—' CYeft rance
CLE -9
Ort>. USE ONLY
chock# 0 � 1 Date: • o`�a-• 15
PLEASE IZEVIER'ALL 3SFiEET5 Receiprg K 1_,r staff:
PARCEL INFORMATION ri'Xisting zortin
Tax Map and Parcal:
Parcel Owner: �-�r, ,
�lv,lp.� \ C;h Y�1�uP /1�iQ�Stntc VA �Zlp�u�
parcel Address: I� �1JV '' "'-1--�-�—�
(include save or floor)
PREWARY CONTACT
who should we call/write concerning this project?
ll� a,n� State C zipo
Address : City I
Office Phone
(t• l �) ��yy'--1�=-i- Ceil��ID t'-rns�il��fn�F/] i a �nlr Y]!�t".Qh� I� ' S .Cf�'Nt<
APPLICANT INFORMATION
Check Any that a 1 : Chan a of owncrslti Change of use Chime off nanno New business
Ruilness Nnme/Type:
i
Previ;otis Business on this site
Describe the proposed business including use, number of employees, number of shi s avail 61e parking space , number of
vehicles, and any additional inform tion that you can provide:^ iT A.0 JA I! c ,
'This Cloarance 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 chat 1 own or have the own oeB permission to use the space indicated on this application. I nlso certify that the information provided
is true and aecutare to lh nowledge, ,1 rave read tho conditions of approvsl� understand thein, and that T will abide by them.
Signatur Printed L-Ye"u
APPROVAL INFORMATION
Approved us proposed [ ] Approved with conditions [ ] Denied
Backflow prevention device and/or currom icn data nooded for this site, Contact ACSA- 977-4511, x117.
( ] No physical site inspection has been done for flits clearance, Therefore, it is not o detormination of compliance with die existing
site plan.
[ ] This sits complies with the site plan as of this date,
Notes;
Building Official Date
Zonlug Official pate.
Other Official Date
County o Albctnarlo Department of Commnnity Development
401 McIntire Road Chorlottesvdle, VA 22902 Voice: (434) 296-5932 rax: (434) 972-4126
n�// RaV lsed 7/1/2611 Page 2 of 3
Intake to complete the following:
Y/6)
Is use in Ll, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
9)/ N
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 applies
Is parcel on private well ortrtrlicr?
If.private well, provide Heal h-B6partment form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applies
Is parcel on septic or pa is sewer?
Reviewer to complete the following:
Square footage of Use: e]�SOO
Y/N
Permitted as: t, S
=^T
Under Section: /d .
Supplementary regulations section:
Parking formula: /
Required spaces: -2-0
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.
Permit # inspector : Date:
Y/N
Will there be any new construction or renovations?
if so, obtain the proper Permit.
Permit #
Zoning to comnlete the following:
Notes:
Violations:
Y /A
If so,'Zist:
Proffers:
Y /Cly
If so, List:
Vari nee:
Y/
If so, List:
SP's:
Y/II
If so, List:
Clearances:
SDP's
i
Revised 7/l/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,
was provided to
[County application name and number]
[name(s) of the record owners of the parcel]
and Parcel Number
manner identified below:
the owner of record of Tax Map
by delivering a copy of the application in the
Hand delivering 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
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].
Signature of pplicant
r
Print Applicant Name
y l7 zoos
Date