HomeMy WebLinkAboutCLE201500158 Application 2015-08-07;e: 2 of 5 07/27/2015 02:31 PM TO:14342968888 FROM: Queena Shi PHO i
3467954790
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1PNNPation for Zonina Clearance
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� CLI'; #�p �
PLEASE REVIEW ALL 3 SHEETS
OFFICE USE ONLY
Check# C-0-SDate-
Receipt# To --1q 1 Staff. $�
PARCEL INIi ORMATIO r-�
Tax Map and Pnrccl: � —' I J] >, Existing 7,oning t•') O'An p,���QU, � j
Pnrccl Owner: Co"' -10 �( tis} -ems
Parcel Address: 17C) %6t(bPV\W Sly• City (,51/ 1 C' .State Zip 21-01
(include suite or floor)
PRIMARY CONTACT
`r
Who should we call/write concerning this project? CA �tCl� l l i;CU -
Address: 1.20 11vr LI.Q City 00U io1Aeei; e State J.AA Zip,124 [
Offlce Phone; L'1;Z:yb ;Aj " Al c Cell # Fax # 6 -mail
APPLICANT INFORMATION
Check any that apply: Change orownership = Change or use Change of came New business
Business Namerrype:6'1 N0,n inn 1) 9H 6 k -s+ 6V IAeAA,
Previous Business on this site
Describe the proposed business including use, number of employees, number of shifts)) available parking spaces, number -of
�Yehielm wld }tny additiQnal information Owl you can provick; %i/qb) n(A)111e�c1lr�
*This Clearance will only be valid on the parcel for which it Is nppruvcd. 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 ecirtifythat the information provided
is true and accurate to the best of my knowledge. ll have read the conditions of approval, and I understand them; and thatI will abide by them.
Signature ��{ fq'U�1/\ YL t G%J Printed �1n W1 an �irt o
APPROVAL INFORMATION
Approved as proposed [ ] Approved with conditions [ ] Denied
[ ] Backflow prevention device and/or ctrrent test data needed for this site, Contact ACSA, 977-4511, x117,
No physical site inspection has beat dont for this cicaranec. '�hi rdQrq , it is not,st dotcrm.itt1ii4n of yotnpl jsinw with the existing
site plan.
[ ] This site complies with the site plan as of tins date,
Notes:
Building Official �— Date
Zoning Ofricial? Date
Ether Official aA:±rl.z� - Date
l
County ot'Albemarle Department of Community Development
401 IY1c]ntire Road Chei'lotiesville; YA 22902 'Voice: (434) 296.5832 Fac: (434).972-4126
.Revised 7/1/201-1 Page -2 of 3
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;e: 3 of 5 07/27/2015 02:31 PM T0:14342968888 FROM: Queena Shi
3.467954790
lntaice to complete tite following:
Y/N
Is use in LT, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
c ), I N
Will there be food preparation?
If so, give applicaart a Health Department form,
Zoning review can not begin until we receive approval 5•om Health
Dept, FAX DATE
Circle the one that applies �—
Is parcel on private well o ublic water
If private well, provide Realt apartment form.
Zoning review can not begin until we receive approval from Health
Dept, FAX DATE
Circle the one that ap
is parcel on septic 6public sewer9
YlWilll ' ou be putting up a new sign of any kind? If so, obtain proper
Sign permit,
Permit Inspector: Date:
#
Y / Notes:
Wil01i re be any new construction or renovations?
If so, obtain the proper Perm it,
Permit #
Reviewer to complete the following:
Square footage of Use: L U U
Y( N
Permitted as:l
Under Section`2 • 2� 1
Supplementary regulations section:
Parking formula:
Required spaces:
Y / 2�
Items n be verified in the field:
Zoninu to complete the folIovviliLY:
Violat• 'ts:
Y /
If S&' -fist:
P-1,oif s:
/ N
Cf so, List;
" /9 6 3 - �-
Variance:'s:
6)/N
If so, List: � �
t�/N
Lf so, List: Q �
5'o q
Clearances;
SDP's %�
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Revised -7/1/2011 Page.3-of 3 --- ---- -- --1
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;e; 4 of 5 07/27/2015 02;31 PM 70;14342968888 FROM: Queen& Shi
3467954790
CERTIFICATION THAT NOTICE OF THE
APPLICATION HAS BEEN PROVIDED TO THE LANDOWNER
Tltis form must accompany Zoning applications (Home Occupation, Zoning Clearance, Zoning
Atlurinistrator Determurations or Appeals, Sign Permits, Building Permits) if the application is not the
owneI,.
T certify that notice of the application, t✓L-E 201 S- % 5
[County application name and number]
was provided to the owner of record of Tax Map
[name(s) of record owners of the parcel]
and Parcel Number by delivering a copy of the application in the
manner identified below:
Hand delivering a copy of the application to
[Marne 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
Mail i ng a copy of the app] ication to
[blame 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 fol.lowing 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
651 Dloy1
Print ApplicantNaune
Date
PHO
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