HomeMy WebLinkAboutCLE201500183 Application 2015-09-04. cri na.
Application for Zoning Clearance
CLE # a O N - 11S
OFFIC1, U E ONLY
PLEASE REVIEW ALL 3 SHEETS Check # qqG10 Date; J
Receipt # 1 Qi Staff:
PARCEL INFORMATION �� �h
Tax Map and Parcel: Existing Zoning
Parcel Owner: V C Jv, < < r\,L
Parcel Address: City �r[o 2x�l Srate VA Zipgaclfl
(include suite or floor)
PRIMARY CONTACT
Who should we call/writescconcerning this project? M Q `ell
Address: ' s_e—Iffikity ate ZipO"/®
L '
Office Phone: r� ell # ss -66 .2-- Fax # f 3 1iK1916 E-mail` r
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Easiness Name/Type: � �` e �-�`�
Previous Business on this site tAJ
Describe the proposed business including use, number of employees, number of shifts, available parking spaces, number of
vehicles, and any additional informat' n that you can provide:
AS -JEM100 010 lnuhll=
*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 know edge. I have read the conditions of approval, and 1 understand them, and that I will abide by them.
Signature
T ` Printed ypl
APPROVAL INFORMATION
Approved as proposed [ ] Approved with conditions [ ]Denied
[ ] 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 Date
Zoning Official Date
Other Official Date
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:
Reviewer to complete the following:
Y 1,
Square footage of Use: A/10
Is uIsein LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
3 / N
Permitted as:
YOtereZS.2•
J
Will be food preparation?
Under Section:
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 or�ler?may
If private well, provide Hea ment form.
Zoning review can not begin until we receive approval from Health
Required spaces:
Dept. FAX DATE
YI
Circle the one that applies
Items to be verified in the field:
Is parcel on septic or is sews ?
YIN
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Inspector : Date:
Permit #
Notes:
YIN
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the following:
Violations:
Violations:
Proffers:
If
If so -,-fist:
soist:
Vara e:
Y/W
SP's:
Y/
If so, List:
If so, ik
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 lite
owner,
I certify that notice of the application,
[County application name and number]
was provided to
[name{s} of the record owners of the parcel]
and Parcel Number
manner identified below:
the owner of record of Tax Map
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].
SiWgnat—urePApp—p*ficant
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Print AjpiZcan&t Name
Date