HomeMy WebLinkAboutCLE201500071 Action Letter 2015-06-18Application for Zoning Clearance
CLE # Wit}'t,
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OFFICEE NLY
PLEASE REVIEW ALL 3 SHEETS
Check # Date: - 151,
Receipt # Staff
PARCEL INFORMATION
Tax Map and Parcel: ( b ��j Existing Zoning
Parcel Owner: P9111te's
,.,,f U1Q-/&&D()A)tate
ParcelAddress: 13�� `Yil,l%k�i,07,1/ i City Zip
(include suite or floor)
PRIMARY CONTACT, %,
9
Who should we call/write concerning this project? �(t
�� l �1. R( CityAACGX �"l State V �' ZipAddress: /� ,iP
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Office Phone: .� Cell # Fax # E-mail
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APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name/Type:
Previous Business on this site
Describe the proposed business including use, number of employees, numb�gr of hifts, available parking spacg�, nrber of -
ve icles, an any additional 'information ghat you roan p� de . �t f�� M K j 19a ' l f 01-el LCG�� � . �
5 Ut 0 %GL���" °� 1
*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 oW91 r ave the owner's permission to use the space indicated on this application. I also certify that the information provided
is true and accurate to e bes my laro dge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature Printed
APPROVAL INFORMATION
[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 nota determination of compliance with the existing
site plan.
[ ] This site complies with the site plan as of this date.
Notes:
Building Official ADate
Zoning Official Date r
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 7/1/2011 Page 2 of 3
Intake to complete the following:
Y1
Irl
Is use in LI, HI or PDIP zoning?
Engineer's Report (CER) packet.
If so, give applicant a Certified
Y /
Will Ere 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 op blic water?
If private well, provide Hea Department 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 u�sewer?
Y /
WillQu be putting up a new sign of any kind?
Sign permit.
Permit #
Reviewer to complete the following:
Square footage ofUse:
WAII(I L Sl
2,,�tted
as:
Under Section:
Supplementary regulations section:
Parking formula: I I w k (l e
Required spaces:
VN
I ms to be verified in the field:
2
If so, obtain proper
Inspector :%Cl� Date:
[is
Y /
Wilice re he any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the following:
Alf vl_I. i
n ! Q
A
CWOV)Q,1 K--6 cwt ,
ViolA,ons:
Y/CN)
If s moist:
Proffers:
Y/N
If so, List:
Vari e:
Y /
If so, - ist:
F's:
N
-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
This form must accompanymning applications (Home Occupation, Zoning Clearance, Zoning
Administrator Determinations or Appeals, Sign Permits, BuildingPermits) ifthe application isnot the
owner.
I certify that notice of the application,
[County application name and number]
wasrovided to `�'�'�� /� ��> the owner of record of Tax Map
p
[name(s) of the record owners of the parcel]
and Parcel Number 4wft, by delivering a copy of the application in the
manner identified below:
�W f%� f7
Hand delivering a copy of the application to ` (.C��—t J
0
[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].
( I
Signator 'of KppjZant
Print pplicant Name
Date