HomeMy WebLinkAboutCLE201500136 Application 2015-07-20Application for Zonin Clearance�`u''�
CLE #
PLEASE REVIEW ALL 3 SHEETS
OIFFICE U E LY
Checic# bo Date:
"l
Receipt # i bW-A� Staff:
PARCEL INFORMATION,
Tax Map and Parcel: 1 ` Existing Zoning C -a
Parcel Owner: �)be-ntaw�-e-
/,�
Parcel Address: City &!A a�l� t �5 cj.cc tate Zip ZZ�10 /
(incl de suite or floor)
PRIMARY CONTACT
fy-
Who should we call/write concerning this project.
Address 31-V1 �Cd/LCe� /�V . City /��rLdl State �� Zip zz94Y�
efirce Phone: (� 474- Qo0 Cell # �(3�- Fax # AJ14 E-mail �Ue yo U,,-�� d��
V6,9-
09
APPLICANT INFORMATION
APPLICANT
Check any that apply: Change of ownership Change of use Change of name '� New business
42,0�e //G' �" ��' �' c
Business Name/Type: CJ 16-14
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: Me -1 y,tl
1U, .%.- 2
*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 requirdd.
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 aAaccurto the best of my knowledge. I have read the conditions of approvall,,and I understand them,aand that I will abide by them.
Signatulei Printed tJGe �Cci "T
MATION
APPROVALropos!
Approved as [ ] Approved with conditions [ ] Denied
] 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 �— Date `f t
Zoning Official 0� Date
Other Official Date
County otAlbemarle i)eparrmenr of k.ommunny Leveiulnucut
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (434) 972-4126
Revised 7/1/2011 Page 2 of 3
0
0
Intake to complete the following:
Y / 8
Is use in LI, I-II or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y / lel
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 pZpartm�ernt
?
If private well, provide Health form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applie
Is parcel on septic or ub is ewer
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 constriction or renovations?
If so, obtain the proper Permit.
Permit #
Reviewer to complete the following:
Square footage of Use: -2-0()
/N
ermitted as: U�� j ce—
Under Section: 2,y . 2 - l
Supplementary regulations section:
Parking formula:
�J�
Required spaces:
Y/ tvl
Items to be verified in the field:
Inspector: Date:
Notes:
1jujiA 11g, w wu. .... .... ............
Violati ns:
Y/ )
If so, List:
Proffers:
Y/(§"
If so, ist:
Varig ce..
Y/&
If so, List:
SP's:
(j/N
If so, List:
6 5-2/
yrs
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 accompany zoning applications (Home Occupation, Zoning Clearance, Zoning
Administrator Determinations or Appeals, Sign Permits, Building Permits) if the application is not tine
owner.
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
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].
Si not i, of Applicant
Print Applicant Name
D