HomeMy WebLinkAboutCLE201500196 Application 2015-10-12(ff A(
Application for Zonin r Clearance
CLE # 9
OFFICE U E ONLY
PLEASE REVIEW ALL 3 SHEETS Check # � Date, C, �— [
Receipt # I Staff: S�
PARCEL INFORMATI O j ^
Tax Map and Parcel: 'J lle C, Existing Zoning r ParcelOwner: Q, (Q ,g 2 I.bfWllhX 0 U,
Parcel Address: - %City l.fp(4 State Zip Fogg
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project?
rr rr Cit u t
Address: l �{ y
Office Phone: ( ) Cell4S 4 ZAZ V40x 4
APPLICANT INFORMATION
Check any that apply: Change of ownership C
Business NamelType:
State V ['I Zip
E-mail(ACUVeof
of use Change of name
,I z1, (.Q S
Previous Business on this site
Describe the proposed business including use, number of emplo e , number of
vehic es, and an additions information that you, can provide:
S
*This Clearance will only be valid on the parcel for which it is approved. If you change, inten
Clearance will be required.
ew business
spaces, number of
or move the use to a new location, a new Zoning
I hereby certify that I own or have the ovnser's permission to use the space indicated on this application. I also certify that the information provided
is true and accurst o the b my ow edge. I Aave read the conditions of approval, and I understand them, and that I will abide by them.
Signaturd
Printed
APPROVAL IN RMATION
['Approved as proposed [ ] Approved with conditions [ ] Denied
[ ] Backflow prevention device and/or current test data needed for this site. Contact ACSA, 977-4511, x] 17.
[ ] No physical site inspection has been done for this clearance. Therefore, it is not a determination of compliance with the existing
site pian.
[ ] This site complies with the site plan as of this date.
Building Official
Zoning Official
Other Official
Date ct 114 t S:
Date 4 Irs
Date
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (434) 972-4126
Revised 7/1/2411 Page 2 of 3
Intake to complete the following:
Yuin
Is LI, H1 or PDIA zoning? lfso, give applicant a Certified
Engineer's Report (CER) packet.
Y /�
Will ere be fond 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 applies
Is parcel on septic or public sewer?
YIN
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit. sfox ®���
Permit # l�
YIN
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the foll
Violations:
YIN
If so, List:
Variance:
YIN
If so, List:
Clearances: e 191 A.
h�
Reviewer to complete the following:
Square footage of Use: 190
I N
ermitted as: _ UL
Under Section: V
Supplementary regulations section:
Parking formula:
Required spaces:
YIN
item be verified in the field:
Inspector : Date:
Notes:
Proffers:
YIN
If so, List:
SP's:
YIN
If so, List:
SDP
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 dministrator Determinations or Appeals, Sign Permits, Building Permits) if the 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:
I/ 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]
the owner of record of Tax Map
by delivering a copy of the appl ication in the
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].
7
Signa re pplicant
Print Ap icant Name
Date