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HomeMy WebLinkAboutCLE201500149 Approval - Agencies 2015-09-02c� nt.r Application for Zoning Clearance '` CLE # DO'S- ` � � 'i� ..t,. OFFICE USE ONLY -I —a l—I PLEASE REVIEW ALL 3 SHEETS Check # I C) v& Date; Receipt # 0 —1 GX5 Staff: PARCEL INFORMATION Tax Map and Parcel: 6 Existing Zoning Parcel Owner: Parcel (include suite or Soo ,�s `5 city_ � [s ✓0�) State V4 Zip PRIMARY CONTACT I I Who should we call/write concerning this project? / - /r�Q © 1 J City State V Zip�Zy� Address : ��p� Office Phone: L� `i " # L Fax # E-mail +T APPLICANT INFORMATION Check any that apply: Change of ownership Change of use Change of name New business Business Name/Type; Previous Business on this S Describe the proposed business including use, number of employees, number of shifts, available vehicles, and any additional information that you can provide: 1114 2MQn301QL'gAa of *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 will abide by them. Signature os -v* .. Printed AOVAL INFORMATION [ Approved as proposed [ ]Approved with conditions [ ]Denied [ ] Backflow prevention device and/or current test data needed for this site. Contact ACSA, 477-4511, 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 Date C ( t{ 1 Zoning Official Date Other OfficialDate - -7hg 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 Intake to complete the following: YIN Is use in LI, HI or PDIP zoning? If so, give applicant a Certified Engincer's Report (CER) packet. Y°f/ N !'ill 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 public water? If private well, provide Health Department form. Zoning review can not begin until we receive approval from Health Dept FAX DATE Circle the one that Z'p� Is parcel on septicublic sewer? Qi IN 11 you be putting up a new sign of any kind? If so, obtain proper Sign permit. Permit # Y 1't! Will re 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: _ qS0 - 'S'/N Permitted as: •m Under Section-. , • z Supplementary regulations section: Parking formula: Required spaces: YIN items to be verified in the field: Inspector: Notes: Date: Violations: Y/ If so, st: Proffers: Y1 0 If so, List: P's: /N If so, List: Variance: -tN If so, List: SDP's Clearances: 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 A(IministratorDeterminations or Appeals, Sign Permits, Building Permits) if tine 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: L' Hand delivering a co of the application to copy the owner of record of Tax Map by delivering a copy of the application in the [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]. Signature of Applicant Print Applicant Name 9/1// Date