HomeMy WebLinkAboutCLE201500209 Application 2015-11-20Application for Zonin Ciearance Y��"
CLE # QCT — �� -
OFFICE USE ONLY
PLEASE REVIEW ALL 3 SHEETS Check # 3a S$ 70Date: 14 '(
Receipt # 1 I X63 Staff:
PARCEL INFORMATION
Tax Map and Parcel; _Il�t —_� " R Existing Zoning
Parcel OwnerTYI _•T.tl��c'�ir. _ T _
Parcel Address __ _i-dl �,emT� mite i City Chi IL State eA
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project?
Address; City _ CU;1iL State ud Zip-L
Office Phone: l'Y�j) jdS IM37 Cell # Fax # E-mail
APPLICANT INFORMATION
Check Any that apply: Change of ownership Change of use Change of name New business
Business Name/Type: g6 Vt '� ! e �e
Previous Business on this site *1
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: C"h t j fig• T„ t .GSL _ Id
a � _ 7u • .�
*This Clearance will only be valid on the parcel for which it is approved. If you change, intensify or move the use to a now location, a new Zoning
Clearance will be required,
I hereby certify that I own or have the owne>'s permission to use the space indicated on this application. I also certify that the information provided
is true and accvm to the best of my knowl*e. I have read the conditions of approval, and I understand thein, and that I will abide by them.
Signature Printed ;; {- L
it--
APPROVAL INFORMATION
Ij Approved as proposed [ ] Approved with conditions [ ] Denied
Backflow prevention device mWor current test data needed for this site. Contact ACSA, 9774511, x 117.
[ ] No physical site inspection has been dons for this clearance, Therefore, it is not a determination of compliance with the existing
site plan,
[ ] nis site complies with the site plan as of this date,
Notes:
Building Official Date
Ito
Zoning Official Date 11131"0
Other Official Datc __
County of Albemarle Department of Community Development
401 McIntire Road CLarlottesville, VA,22902 Voice: (434) 296-5832 Fax: (434) 972-4126
ReviaW 7/1/2011 Page 2 of
Intake to complete the folio'wing:
Y 9 If so, give a applicant a Certified
Is �n LI, HI or PDIP zoning. PP
Engineer's Report (CER) packet.
Y 11�1
Will ere be food preparation?
If so, give applicant a Health Department form.
Zoning review can not begin until we receive approval tfiom Health
Dept. FAX DATE
Circle the one that applies
Is parcel an private ►veli or ublic watt
if private well, provide Health r rnent form. caval from Health
Zoning reviewean not begin until we receive app
Dept. FAX DATE
Circle the one that anpublle:s:clv��er?
Is parcel on septic d
Y ! T1 kind? If so, obtain proper
W ill you be putting up a new Sion of any
Sign permit,
Permit # �---
Y�
Will there be any new construction or renovations?
if so, obtain the proper Permit.
Permit 11
to
Y1
If so - List:
-8arianec,
1N
if so, List: VA
enrances:
Reviewer to complete the f011owintg:
Square footage of Use:
4mlilzd as:
Under Section:
Supplementary regulations section:
parking formula;
Required spaces:
Y t 3-f
ltcros o be verified in the ficlti:
InspectorDate::
Notes:
Y 1,y_N
If 30, tst:
Sr' S:
Y!
If so, List:
Revised 711RDI I Page 3 of 3
CERTIFICATION THAT NOTICE OF THE
APPLICATION HAS BEEN PROVIDED TO THE LANDOWNER
This form must accompany zoning applicadow (Horne Occupation, Zoning Clearance, Zoning
AdministratorDeterminadons orAppeals, Sign Permfts, Building Permits) if the application is not the
owner.
I certify that notice of the application,
[County application name and number]
was prodded to the owner of record of Tax Map
[name(s) of the record owners of the parcel]
and parcel Number by delivering a copy of the application in the
7manna � entified below:
Hand delivering a copy of tate 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 entityl
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
lac � L A.1 & »'1 C .'.—
Print Appl icant Name
_ Q (o -.)Gi
Date
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