HomeMy WebLinkAboutCLE201500241 Application 2015-12-17Application for Zoning Clearance
CLE #
OFFIt NLY
PLEASE REVIEW ALL 3 SHEETS CheckN Date:
p N Salt:
Tea Map and Parcels Mo. F�isfiag Zaate
ParedOtraer:
Parcel Addresu"!15 EVO
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(in sutteortlao 111 �v
PRIMARY CONTACT � T[t R ey
Who aheuld we calthrrite concar�ting th Project? ! 1�_
Addrmu -MOfAjtV6VW City +t 3tute
t3lfirx Phrtoe: � �_' kelt N�i�Y ��'az<N &ma11
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Cheek any that apply: Chante of awnerahip Change of use Chanes of tome
BystaaasNamvType: Qom/ r /,7"T
FMWoua Business an this alta p
Describe the proposed business Including not, cumber of emploYpft number ofabift� avaW W par g spa a of
rohi and any addhional ittforon that you C49 provlda: tu I f- Q�1 CR—
'rile Cle nmw will oar be valid on !bo parcel tier which ilia approved. if you cheog [NOW& or wove pie unto a saw location, a eew zona j
Ckw am 0111 be n quWa
1 hereby on* that 1 own or hara the aw es permission to use do tpaoe iodiaatad on Ibis appikedon. I also oath That the lnfomad n provided
ls truaand aecueate m . I rad the gond f spptvval, and 1 understand them, and thou 0111 abide by them.
5rgaalttea Prinitd ��v�
0 Appmvo6 as pmlond f I ApptwW with conditloos [ j Denied
[ ] Barddbw pmvamoa device andfor cutrew an data neoded for"site. Cantacl ACSA, 477.4511 x117.
t ] No physical site Inspection has bean dans for Ibis elearauoe. Tberefor% it is not a domminetion of complinum with tho exie ft
sift plea.
[ I Thle site camplias with the ala planes of this dam
Notes:
County orAllmnarle Department of Community D—etr�oprnint
461 Wfdatire Read Charlottes ik VA 22M Voice: (434) 296.832 Fan: (434) 972-4126
Revised 111112015 Pop 2 of 3
to complete the
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Is LI, M or PDIP aoniag'I Ifso, give applicant a Cortified
EttglneWs ROM (Ceti paclmt.
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1 theta be food preparstioO
If sn, give applieaut a Health l@rartmont form.
Zoa ft review can not begirt undl we reoelvo approval titan Health
Dept. FAX CATZ ___ _._ . _ --
Circle the oar that applies .
Is parcel on private well Wr
Ifprivata well, provide Lorm.
Zoning review can not begin until wa rooeive approval f m health
Dept. FAX DATE
Circle the one that aP
Is parcel on septic or sews
YIN
Will you be putting up a naw sign of any kind? If so, obtain proper
Sign permit.
Permit d
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Will there be any now construction or renovations?
If so, obtain the: proper Permit.
Permit it — V
to complete the
(V/ N
If so, List:&kQ ._ _W
Rig: if
Cisaraaees:
Reviewer to complete the
Square faotsge of Use: 3-/Z
(S / N
Permitted as:
Under Section: Z.
Supplementary regulation section:
Perking formula:
Required spaces:
A.4R4a
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Items to be verified in the field:
Inspector • Date:
Nates:
Proffers:
1)/N
If so, List:
r
SP's:
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ifso,Liar
SDP's
SSP �Y_9c?
Revised 11/1J2015 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 orAppeals, 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]
the owner of record of Tax Map
and Parcel Number by delivering a copy of the application in the
manner identified below:
)C 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].
v
Signature of Applicant
Print Applicant Name
fr-r �-/�'
Date