HomeMy WebLinkAboutCLE201500226 Application 2015-11-05Application for Zoning Clearance
CLE #
OFFICE USE ONLY
PLEASE REVIEW ALL 3 SHEETS Check # _a, Date: J
Receipt # Staff:
PARCEL INFORMATION V1 C) (, t
Tax Map and Parcel: Existing Zoning_
Parcel
S
Parcel Address: C S:S 1 City
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project? �^
Address
(1Gity S �� _ State
Office Phone: 6)eA " ell f `Fax # E-mail
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name/Type: ry qY`
Previous Business on this site -
Describe the proposed business including use, number of em ees number of shiftavailable par ing spaces, number of
vehicles, and an additio al 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.
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 trueccurate to the best of my knowledge. 1 have read the conditions of approval, and I understand them, and that I will abide by them.
Signatu Printe%�
�LPPROVAL INFORMATION
�e1 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 I I -y
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 I 1/1/2015 Page 2 of 3
Intake to complete the following:
Y
Is u on L1, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y
Will a 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
on private well or public
If private wideHealthDeepartment farm.
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 I/ N 1
Wi u be putting up a new sign of any kind?
Sign permit,
Permit #
If so, obtain proper f
YC
Willt 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:
I/ N
Permitted as: , Jp
Under Section; 'r ('
Supplementary regulations section:
Parking formula:1V
> zekl) �
Required spaces:
It y
Itenrs to be verified in the field:
Inspector • Date:
Notes:
solations:
/N
SD, List:
4QJ
Pro rs:
Y/
Ifs , ist:
Variance:
0/N
If so, List: T` s�
SP's:
�/N
so, List:
!` - S
Clearances:
SDP's
Revised 11/1 /2015 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
mariner 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 '1Q " \ C r t
[Name of the recor 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 to the following address:
Date
[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