HomeMy WebLinkAboutCLE201500114 Application 2015-06-08` llS +1 f,lff
Application for Zoning Clearance-���,�.-+''
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CLE # � '
OFFICE US LY
PLEASE REVIEW ALL 3 SHEETS Check # Date,
Receipt # Staff:
PARCEL INFO :IT 0 � o�
Tax Map and Parcel: ��� �� Existing Zoning
Parcel Owner: � � rt 1f" �� j , �1
Parcel OS' 1- city 11 r(o l��Sy Ile state V zip °�02�%�
I arcel Address: �� -� �1 L1y��
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project?
Address:
1ciN' �' (t tom' Ctil�l City �ih� rc(, - State V f Zip c=9�
Office Phone: q3 6� ����a`�Cell# Fax # E-mail ':5ro-5vlCSW � �C� h0(3 0'Co
ir
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name 7C New business
Business Name/Type: bv�52 �t� �C.� ` -a—A4
Previous Business on this site
Describe the proposed business including use, number of employees, number of shifts, available parkin spaces, number of
vehicles, and any additional information that yo��
u/ can provide: c
L V e'n t VVI 0 IN { T� o r` c� '- �r
C�
*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 th I o I n or have the owner's permission to use the space indicated on this application..I also certify that the information provided
is true and accur a to t, e best of my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature (AJC J i / ' tPrinted Sod
APPROVAL INFORMATION Approved with conditions Denied
] Approved as proposed [ ][ ]
[ ] 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 C Date C�
Zoning Official Date
Other Official Date
--- -
County—of— Albemarle Department of Community Development - --
401 Mclutire 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:
Y/
�T�
Is u m LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y/�
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 or plic wa er?
If private well, provide Healt � rtment 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 �Iicsewer
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 #
Reviewer to complete the following:
Square footage of Use:
f / N
Permitted as: OPC
Le
Under Section:
Supplementary regulations section:
Parking formula:
Za0
Required spaces:
Y/N
Items to be verified in the field:
Inspector : Date:
Notes:
Zoning to complete the following:
Violations:
Y /o
If so, List:
P offers:
&5/ N
If so, List:
4
03-3
Vag jalrt�ce:
Y /�AIJ
If so, List:
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
Thisform 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,
V Hand delivering a copy of the application to
the owner of record of Tax Map
by delivering a copy of the application in the
[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].
09614.70
`Signature of Applicant r
Print Applicant Name
Date
1405
ROLKIN CT.
Suite 101
1,047 Sq. Ft.
$18.50 Sq. lit.
Plus Utilities
Building Lobby
VIRGINIA LAND COMPANY- _ REALTORS
OF CI-MRLOTTES ILLE, INC. Owner:Broke;
196 R1VERBEND DRIVE . P.O. BO: 5147 . CHRRLO i i ESVILtLE. vii 22906