HomeMy WebLinkAboutCLE201500211 Application 2015-10-26Application for Zoning Clearance ,
CLE # 90 1 S- — '� 1
�' A P
.OFFICE USE OY
PLEASE REVIEW ALL 3 SHEETS Check # C LADate: f 6 * —
Receipt # 10 i Staff.
PARCEL INFORMATION /
Tax Map and Parcel: _tel ^� �®_ d Existing Zoning ttlz) 1'! �✓ __
Parcel Owner: G /t,f� a. �� Y �f I—L c,
Parcel Address: 30 +% 6DA VOX, ]�,(i CityState V �7' Zip alJ
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project? d/
Address -6000 City vt lek State //;z Zip
Office Phone: Cell # Fax # E-mail i�ff
Y ^�
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name/Type:
Previous Business on this site
Describe the proposed business including use, number of employe4;s, number of shifts, available parking spaces, number of
vehicles and any addi 'onal infor tion that you can provide: ketilo Liles /7 t� r_.�a� ISS It L-- IA-�k 111
o
*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 o4ave the owner's permission to use the space indicated on this application. I also certify that the information provided
is true and accurate to tett 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
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 1 J
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:
Y/N
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y
W12e 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 well o ublic wat
If private well, provide Health epartment form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one
Is parcel on septi or public sewe
Y
Wi you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y
Wi ere be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the following:
Reviewer to complete the following:
Square footage of Use:
Per
/Nlmitted as: PA TA
Under Section: ..
Supplementary regulations section:
Parking formula:
Required spaces:
Y/N
Items to be verified in the field:
Inspector : Date:
Notes:
Violations:
YIN
If so, List:
Proffers:
Y/N
If so, List:
Variance:
Y/N
If so, List:
SP's:
YIN
If so, List:
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 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:
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].
Si pplicant
vt
nt Applicant ame
J,4)
Date
Date