HomeMy WebLinkAboutCLE201500122 Application 2015-06-24Application for Zoning,Clearance`��
CLE
PLEASE REVIEW ALL 3 SHEETS
OFFICE USE ON Y '
Check # 6 f-7 � Date: G
Receipt # 10 004,0 Staff: fts
PARCEL INFORMATION ) x x p / cbt-nlnet
l�� �_�U U- �/7 !�� Existing Zoning
Tax Map and Parcel: 4 SAt
Parcel Owner: //r�aG d t/-7 /�%^S C_
Parcel Address: (.aI5 v1 0 412) 4 City Chol_1 e_5 -u )mstate ✓� Zip �V
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project?Q
Address: �S G�DUCO�Y�G �e �� City h r d-#eSV /CState 04 Zip 9,9%
Office Phone: I( 3y,q'7574606 Cell # �3(/g7 �7 3 Fax # /'1 "�5 / 7G E-mail � u ew64Q
APPLICANT INFORMATION ,
Check any that apply: Change of ownership Change of use ✓/�� Change of name New business
Business Name/Type: r �✓'
L .
Previous Business on this site✓J%Y)�i� 1� �/ /�%�' f✓ l�UllSs-lS
Describe the proposed business including use, number of employees, number of shifts, available,parking spaces, number of
vehicle , and any additional information that you can provide: 7�`U�i:
�n G7rp�i A0 ye h1,rLL_ -, �—
*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 willabide by them.
Signature Printed
APP AL INFORMATION
ved as proposed [ ] Approved with conditions [ ] Denied
[Wckflow
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 OfficialD ate
Zoning Official Date
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
W
Intake to complete the following:
Is/
Is us n LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y/N
Wil re 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 public 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 ap ' s
Is parcel on septic o public sewer?
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit. ,y n� �-,p �n (j ,,n�
Permit # 9P � � A 4 i i 04 (�1,�'C� N {7 � Im i
Y/N
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the following:
Reviewer to complete the following:
Square footage of Use: n
Q N
mitted as:
Under Section: r 1
Supplementary regulations section:
Parking formula: /�� Y)ECtJ
Required spaces:n34
Y/
Viol ' s:
Y
If L'
Props:
Y N
Ifs , -st:
Vae:
Y N
If S, ' t:
P's:
Y/N
so, List:ai
c
Clearances: I
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 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,
[County application name and number]
was provided to �y�/C �a �"%7%P%"Sthe owner of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number Z� 666 by delivering a copy of the application in the
manner identified below:
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 of Applicant
S: /vim
Print Applican Name
Date
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