HomeMy WebLinkAboutCLE201500195 Application 2015-10-05(� Al
Application for Zoning Clearance ��;
CLE # �t:5 4 S — l `moi S
'1 !7lR;Iti�' �;
OFFICE U Y
PLEASE REVIEW ALL 3 SHEETS Check # Date:
Receipt # 1U1 UR Staff:
PARCEL INFORMATIONN
Tax Map and Parcel: I e_
a I�1<Ifflldw/"Yrl�l</J/'/'trwsL�c�.�=
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(imelude suite or '�- � 1
PRIMARY CONTACT
Who should we call/write concerning this project? ,
' ,
Address: __ _ .
CityeP/1J/.State
Office Phone: {�
ell � Fax # 9`_.� E-mail
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APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business NamelType:
Previays usiness on this site `
f&scliC proposed business including use, number of employees, number of shifts, available pa_rg spac,es, nu er of
vehicles, and avv additional inforrn$Iion t#Rlyou_can provide: : Ly? l _& •��rr- j
*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
APPROVAL INFORMATION
>4 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.
Notes:
Building Official
Zoning Official
Other Official
Date 'I tt �
Date
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
J
Intake to complete the following:
Y 1
Is USQ11, HI or PDIA zoning? if so, give applicant a Certified
Engineer's Report (CBR) packet.
Y1�
W 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 ►vell 06 bis wale
Ii'private well, provide Heal spar ment form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that apphe
Is parcel on septic o rrblic sewe .
Y 10
Will you be putting up a new sign of any kind?
Sign permit.
Permit #E
If so, obtain proper
Y1
Wi11 Cere be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Reviewer to complete the following.-
Square
ollowing:
Square footage of Use: —ifj� -
Y)/ N
Permitted as: i'yl�/%'rm 1 jp ➢ —
Under Section: Qo;;Li?A
Supplementary regulations section:
Parking formula:
MA
Required spaces: /
YI
Its be verified in the field:
Inspector: Date:
Notes:
Zoiling to complete the following:
Violations:
Y /(,
Ifso, Ist:
Proff s:
Y I
If so, tat:
SP's:
N
` f so, List: D
Variance:
Y l6jj1
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 acconWanp zoning applications (Home Occupation, Zoning Clearance, Zoning
Administrator Determinations or Appends, 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 r. the owner of record of Tax Map
[name(s) of the record owners of the parcel]
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].
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/igg—na-tdure of Applicant
Print A licant Name
,? � j/%, -
Date