HomeMy WebLinkAboutCLE201500161 Application 2015-08-05Application for Zoninlearance
CLE# 15" U
OFFICE USE ONLY
PLEASE REVIEW ALL 3 SHEETS Check # 1023 Date:
Receipt # l 00 X511 Staff:
PARCEL INFORMATION
Tax Map and Parcel: l0 j (,I — Z Existing Zoning Wnhmm
i
Parcel Owner: 5vs
5 Z (j2{lG✓v�Gt orcity 0'. o' SVState
Parcel Address: �
(include suite or floor)
PRIMARY CONTACT project? L_d, r � es (, ,
Who should we call/write concerningthis ro ect.
Address: 11� C� City vvV�0tate _
i � — ��Fax ## 1& -7� E_mail
Office Phone: (_) Cell #
CANT INFORMATION
Check any that a
Business Name/Type:
Previous Business on this site
Change of ownershi
(Z
✓a- zip 22-9
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all rc�-.
<- �1
zip 229 �
'pe.SCL - (A
nn Change of use Change of (name V New business
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Describe the proposed business including use, number of employees, number of shifts, available parking spaces number
vehicles, and any additional information that you can. provide: �UC� �v t� �E'� t 'L� `
--/ t
*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.
r's permission to use the space indicated on this application. I also certify that the information provided
I hereby certify that I own or have the otinle
is true and accurate the best of my knowledgve read the conditions of approval, and I understand them, and that I will abide by them.
Signature
(� Printed
APPROVAL INFORMATION ]Approved with conditions Denied.
Approved as proposed [ [ ]
[ ] 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
Zoning Official
Other Official
c
Date y
Date � - tel
Date
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (434) 972-4126
Revised 7/l/2011 Page 2 of 3
CD
Intake to complete the following:
Reviewer to complete the following:
Y / N
Is use in LI, I -I1 or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Square footage of Use: �7
/ N
Permitted as: lhelk
Y/N
Will there be food preparation?
Under Section: .2—
If so, give applicant a Health Department form.
Zoning review can not begin until we receive approval from Health.
Supplementary regulations section:
Dept. FAX DATE
Variat
Y/
If so, ist:
Circle the one that applies
Parking formula:
�� D
Is parcel on private well or public water?
If private well, provide Health Department form.
Zoning review can not begin until we receive approval from Health
Required spaces:
Dept. FAX DATE
Y / N
Circle the one that applies
Items to be verified in the field:
Is parcel on septic or public sewer?
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Inspector : Date:
Permit #
Y/N
Will there be any new construction or renovations?
Notes:
If so, obtain the proper Permit.
Permit #
Zoning to complete the following:
Violations:
Y /
If so;Iist:
Pr
If / /
ist'
f so, ts
Variat
Y/
If so, ist:
SP's:
Y/
If so, ist:
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3
D
CERTIFICATION THAT NOTICE OF THE
APPLICATION HAS BEEN PROVIDED TO THE LANDOWNER
This form must accompany zoning applications (Home Occupation, Zoning Clearance, Zoning
A(IniinistratorDeterillin(itioils or Appeals, Sign Permits, Building Permits) if the application is not the
owner.
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
/ Gus Y (� s s-e-��
V 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]
Oil
Date'
to the following address:
[address; written notice mailed to the owner at the last known address of the owner as snown un
the current real estate tax assessment books or current real estate tax assessment records satisfies
this requirement].
ure of Applicant
Print Applicant Name
V2 -R 5
Date
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