HomeMy WebLinkAboutCLE201500187 Application 2015-09-18Application for ZoninClearance
CLE # 30 I S I !E
OFFICE USE ONLY
PLEASE REVIEW ALL 3 SHEETS Check # 0 i 0 Date:
Receipt # ? o i H S t, Staff:
PARCEL INFORMATION
Tax Map and Parcel:
Parcel Owner: a ° 14%1� ti
Parcel Address: N� City
(include suite or floor)
Existing Zoning el�h&o,: kcn A d
ZIP
PRIMARY CONTACTA'NA �`� ��[',� ?�
Who should weycall/write concerning this project? / j
Address: 9� 4
� �l G i _ City '—mi tfstate �" d Zip I�+'
h,
Office Phone: L y MIN Cell ASO %U'y "Fax # , E-mail bt I I.
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name 14 New business
Business Name/T�pe:
���'% �)♦� �><l� �11i��1L1 ��� �49R,R•i a ra i as;�azs+
Previous Business on this sit
Describe the proposed business including use, number of employees, numbor of shifts, available
vehicles. and.ant+additional information thpt you can provide:
*'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, it 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 approv and I understand fire and that i will abide by them.
Printed L
Signature
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:
Buildingofficial Date. t Z t
Zoning Official Date
Other Official Date
County of Albemarle Department of Community Development
401 McIntire Road ClioriottesvilIe, VA 22902 Voice: (434) 296-5532 Rax: (434) 972-4326
Revised 7/1/2011 Page 2 of
m7 -
CERTIFICATION THAT NOTICE OF THE
APPLICATION HAS BEEN PROVIDED TO THE LANDOWNER
This farm must accompany zoning applications (Home Occupation, Zoning Clearance, Zoning
Administrator Determinations orAppeals, Sign Permits, Building Permits) iftl:e application is not the
owner.
I certify that notice of the application,
[County application name and number]
was provided to U% '-o \Ak4tVSC the owner of record of Tax Map
[name(s) of the record owners oftheparcel]
and Parcel Number 0 3 1 by delivering a copy of the application in the
manner identified below:
\/ Hand delivering a copy of the application to
Gork:o Wows
[Naive 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]
Date .
Mailing a copy of the application to
[Naive 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]
Dee
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].
cmc4sm(�Mw
sippature of Applican 11
G
"rAPpl.licNaives
Date
Intake to complete the following:
Y/l�
Is use Jn LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Yl
Witlt sere 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
Reviewer to complete the following:
Square footage of Use: _, 7:7
til N.
Permitted as:
Under Section: 6,e -s:,
Supplementary regulations section:
Circle the one that applies Parking formula: �f -
Is parcel on private well or ublic w r? If private well, provide Health eparhnent form.
Zoning review can not begin until we receive approval from Health Required spaces:
Dept. FAX DATE
YI
Circle the one that appy Items to be verified in the field:
Is parcel on septic o ublic se r?
Ylg
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit. inspector : Date:
Permit #
Y1 Natea:
Will t ere be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the following:
Viol�sAqns: offers:
Y /(N)/ N
If so`��ist: Iso, List:
bf
Varia_ ce:
Y1t/ N
If go, :st: If so, List:
Clearances: SDP's
3; I -
Revised 7/1/2011 Page 3 of 3
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