HomeMy WebLinkAboutCLE201500118 Application 2015-06-17Application for Zoning Clearance
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CLI{; # 1 - \
OFFICEE ONLY
PLEASE REVIEW ALL 3 SHEETS
Clteelc # WA Date:
Receipt # Staff:
PARCEL INFORMATIONVt^erC� j
Existing Zoning
Tax Map and Parcel:m
Parcel Owner: u '
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Address: \ (1, 11(� City �Q Y t to Zip —�
Parcel
(include suite or floor)
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PRIMARY CONTACT e nn ITS, n n
Who should wee�callfwrite concerning this project.
Address • r ) .� l�l�\V l 'City State Zip
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Office Phone:�Q_Celli��—Fax# E-mail 't .Yll'1� �I�G�VI�'
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name/Type: IM a 55c C'2, nna cvr-Ayyinrlrey'
Previous Business on this site .
Describe the proposed business including use, number of employees, number of shifts, available parking spaces, 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 1 e +til. I
APPROVAL INF RM TION
�(j Approved as propose [ ] 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:
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Building Official Date G_kIL
Zoning Official Date
Other Official Date
County o] Alnemarie lveparraLtenL u1 %,VLLtLttuuLLy "VWVk.o
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (434) 972-4126
Revised 7/1/2011 Page 2 of
J
VAN
Intake to complete the following:
Y /
Is u m LI, HI or PDIP zoning? if so, give applicant a Certified
Engineer's Report (CER) packet.
Y/
Will Here 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 on=11
es
Is parcel on or public water?
If private well, provide Health Department form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the on. hat applies
Is parcel oltp,91
or public sewer?
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: S'O
lb/N
Permitted as: i L 2
Under Section: L-z�2`
Supplementary regulations section:
Parking formula: �� �b
Required spaces: -Z_�-
Y/
Items to be verified in the field:
Inspector ; Date:
Notes:
V11111;4 LV GVIAA AV{.V caw x-- .
Viol tions:
YY/
If SQ, nst:
Prof rs:
Ifso, ist:
Variance:
Y/)
If s, ist:
o
SP's:�;l
Y/V
If so, List:
Clearances:
SDP's2 2%
Revised 7/1/2011 Page 3 of
G
CERTIFICATION THAT NOTICE OF THE
APPLICATION HAS BEEN PROVIDED TO THE LANDOWNER
?his form must accompany zoning applications (Home Occupation, Zoning Clearance, Zoning
Administrator Determinations or Appeals, Sign Permits, Building Permits) if the application is not the
o1pner.
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
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].
0
Signatur f A li oaa
Print Applic ame
ro I C
Date