HomeMy WebLinkAboutCLE201500191 Application 2015-09-23Application for Zoning Clearance
CLE
OFFICE LY Imo+
PLEASE REVIEW ALL 3 SHEETS Check
Receipt # Staff:
PARCEL INFORMATION
Tax Map and Parcel: e, Bxisting Zoning
L •� �t A
Parcel Owner:
. ti r
Parcel Address: L City State a Zip r
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project? �-
C .G'�. Roy— 3 X
'I 7
-:22/5-Address: �/5- rDXF1e_J4_T1rdLL City LAS Zip
Office Phone: tTM .213 Cell # / Fax 0293 �'� E-mail
APPLICANT INFORMATION
Check any that apply: Change of ownership ,�Change of use Change of name New business
Business Name/Type: nO`X�« i .L r_t� f i55GIC . it1 ems.
Previous Business on this site
Describe the proposed business including use, number of employees, number of shifts, available parking spaces, number of
vehicles, and any additional information that 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, a new Zoning
Clearance will be required.
1 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; Printed UP )3& �4- (A_
APPROVAL INFORMATION
Approved as proposed [ ] Approved with conditions [ ] Denied
[ ] Backflow prevention device and/or current test data needed for this site. Contact ACSA, 9774511, 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.
Nates:
Date 9Building Official
laid cS
Zoning Official Date �z3
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 7/1/201 I Page 2 of 3
Intake to complete the following:
Y1
Is a LI, HI or PD1P zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
YIN
Will 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 a plies
Is parcel on Il or public water?
I f private 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 septic or public sewer?
Y/0'
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit 4
Y 1
WiIE1 ere be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Reviewer to complete the following:
Square footage of Use:
O I N nnI
Permitted as: THAI r' LSC eVe_ —
Under Section:
Supplementary regulations section: 196-w
� f,��
eC 10�r �L� �d
Parking formula:
Required spaces:
Y/N
Items to be verified in the field:
Inspector:
Notes:
Date:
Zonine to complete the following:
Violations:
(�
If so` gist:
Pro�rs:
Y 0
If so, List:
SP's:
IN
If so, List:
a /J
Variance:
If so, Mt
495
SDP's
Clearances:
Revised 7/I/2011 Page 3 of 3
CERTIFICATION THAT NOTICE OF THE
APPLICATION HAS BEEN PROVIDED TO THE LANDOWNER
This form must accompany zoning applications (Hoene Occupation, Zoning Clearance, Zoning
Administrator Determinations or Appeals, 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
[name(s) of the record owners of the parte!]
and Parcel Number
manner identified below:
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].
Signature of Applicant
Print Applicant Name
Date