HomeMy WebLinkAboutCLE201500149 Application 2015-08-17Application for Zoning Clearance
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PLEASE REVIEW ALL 3 SHEETS Clieck # Date: t(d., t1
Receipt # Staff.
PARCEL INFORM
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Tax Map and Parcel Existing Zoning,
Parcel Owner: sue, ki rz- sxlr e4lly 1 6mv--,
`/�63 ip��)Y1� City
Parcel Address: &L -&t � /�_ State Zip
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(include (include suite or floor)
PRIMARY CONTACT /Vd
Who should we call/write concerning this project?1-711
Address: 1(r2 je..; QJ�- % City C-4 r1o0CSVdL State Zip 2-7- v%
Office Phone: ( ) 7 -74/-7 gb6Cell4 Fax # E-mail
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APPLICANT INFORMATION
Check any that apply: of ownership Change of use Change of name V New business
Change
Business Name/Type: RJ�SV ALr),,�
Previous Business on this site ( .
Describe the proposed business including use, number of employees, number of shifts, available arldng spaces number of
vehicles and any additional information that you can provide: �/}�,1(� , kt
"This Clearance will only be valid on the parcel for
Clearance will be required.
or move the use to a new location, a new
I hereby certify that I own or !rave 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 rem, and that I will abide by them.
Signature "Yt1l�/ V 'eO Printed P7�, M15
APPROVAL INFORMATION
;�Q Approved as proposed [ J Approved with conditions [ J Denied
j J 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. • I
[ ] This site complies with the site plan as of this date.
Notes:
Building Official Date C �;
Zoning Official Date 0-712-6%5
Other, Official Date
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832Tax: (434) 972-4126
Revised 7/1/2011 Page 2 of 3
Int,ke to complete the following:
Reviewer to complete the #blIowing;
Y / N
Square footage of Use:
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
�\
Engineer's Report (CER) packet.
(YJ/ N
N
Q'If
ermitted as: yYl
there be food preparation?
Under Section; 21)
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
Circle the one that applies
Parking formula:
Is parcel on private well public water?
SDP's
6
If private well, provide Hea t epartment form.
'
Zoning review can not begin until we receive approval from Health
Required spaces: J
1Z
Dept. FAX DATE
- \ /
Y/ 19)
Circle the one that applies
Items to be verified in the field:
Is parcel on septic o ublic sewer.
YG/ N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Inspector : Date:
Y /(D
j
Notes:
Wil sere be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the followinE:
Violations:
Y/
If so, ist:
Prof ers:'
Y/
If so, ist:
Variance: - -
6 N
If so, List: rq p
SP's: -
&)/ N
If so, List:
fJ
Clearances:
SDP's
6
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� Sr I3S
Revised 7/1/2011 Page of
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 orAppeals, 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 the owner of record of Tax Map
[narne(s) of the 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
[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].
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Signature of Applicant j -
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Print Applicant Name
D to