HomeMy WebLinkAboutCLE201500125 Application 2015-06-17Application for Zoning Clearance,.
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PLEASE REVIEW ALL 3 SHEETS
OFFICE USE ONLY
Check # 31 3 Li Date:
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Receipt # 1 003Ys Staff:
PARCEL INFORMA j�j 1 /� i I
00 — 01 O Zoning C'1
Tax Map and Parcel: � tnok Existing
Parcel Owner: A "ie
Parcel Address: City State Zi
(Include suite or floor•)
PRIMARY CONTACT /1
Who should we call/write concerning this project?
A./ ���7L ��ZS City Cjo/16Nksy,/k State Zip�9o3
Address: aal�
Office Phone: 5( 71)Z57 . 5Zys Cell # 7v3.73/•Z076 Fax #7o3 - a1.3791 E-mail i'yan@ �a✓e.�do„ l�Jt��7�%• co.�
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name/Type: (f/oaYC ✓1 dol�1/�u �O`I�age Med
Previous Business on this site
Describe the proposed business including use, number of employees, number of shifts, available arld spac , number of
vehicles, and any additional information that you can provide: o e ��! % e,
Lia D✓a �e�% o
*This Clearance will only be valid on the parcel for which it is approved. If you charWritensify or move the use to a new location, anew Zoning
Clearance will be required.
I hereby certify that I own or have the owner's permission use the space indicated on this application. I also certify that the information provided
is true and accurate to the best of my edge. I lia ad the conditions of approval, and I understandthem, and that I will abide by them.
Signature Printed 1/,✓+
APPROVAL INFO
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
Date
Zoning Official
Other Official Date
County of Atuemarie ueparnnen[ 01 %_U11u11u1111y .UUV.JVP.
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (434) 972-4126
Revised 7/1/2011 Page 2 of
o
Intake to complete the following:
Y/l
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y/
Will Piero 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 public- ?
If private well, provide I��th De neat 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 p lic sew
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 #
4-
. 1 t the folIowin
Reviewer to complete the following:
Square footage of Use: 1yo S•
0/ N.
ermitted as:
Under Section: �-y• 2 °�
Supplementary regulations section:
Parking formula: // 6
Required spaces:
Y/
Items o be verified in the field:
Inspector : Date:
Notes:
Zono com e e
VioSt, ons.
Y / �
If so, List:
Proffe
Y /(1y,/ .
If so,_ist:
Variand :
Y /
If so, ist:
SP's:,
Y / ilk/
If so, List:
Clearances:
SDP's
Revised 7/1/2011 Page 3 of
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
olviler.
I certify that notice of the application,
[County application name and number]
was provided to 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
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 to the following address:
Date
[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 Applie
Print Applicant Name
Date
10 feet
14 feet