HomeMy WebLinkAboutCLE201500236 Application 2015-12-21—T(4
Application for Zoning Clearance
CLE # d l - a *3 f
OFFICE USE ONLY
PLEASE REVIEW ALL 3 SHEETS Check # t 'A KODate: l 16 A "
Receipt # I faA, "i Staff:
PARCEL INFORMATION
Tax Map and Parcel: 2I0 tl lily° W 3000 ! 2 00 Existing Zonin /' yr
n .t
Parcel Owner:
L
Parcel Address: 12-2 0 S e- m� n o 1 e Tra; 1 City �sy; j l C State Zip �e 0
(include suite or floor)
PRIMARY CONTACT _
Who should we calllwrite concerning this project? f u.m er o.—
Address r(3a
Cita' State l 6 !1 ! Zip 2yQ19)
Office Phone: `+00 r`JJrell # ��fi7 ZO l0'
�--) �4x #S'yp • yf3D, ; lrmail �t�; ���� S-lt;�orl s�urrs,c.�
APPLICANT INFORMATION
Check any that
Business Name/Type:
Previous Business on this site
VPS
of ownership Change -of use
wens e.nee- % C-ro c C. n
of name New business
ion V" 164S -Tb k14
*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
istrue and accurate to the best o knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
i
Si tyre 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 t
Zonfug Official Date /r- Z0�
Other Official Date
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 2%-5832 Fax: (434) 9724126
Revised 7/1/2011 Page 2 of 3
Intake to complete the following:
Y 614)
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y J/ N
ill there be food preparation? undC'r 15 Seal,
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 water?
If private well, provide Heal epartmen orm.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Cizcle the one thatapph ,
Is parcel on septic public sewer?
Y IU
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y l
Will hrdre be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Reviewer to complete the following:
Square footage of Use: -2-7
YIN
Permitted
Under Section:
Supplementary regulations section:
Parking formula:L p „�
Required spaces:
YI
Items to be verified in the field:
Inspector : Date:
Notes:
Zoning to com Tete the following:
Violations:
Y/O
If so, List:
Pro rs:
Y/
If so, List:
V�riance:
rN
�
If so, List:
SP's:
Y /69
If so, List:
--- e4rZ _,..
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 orAppeals, ,Sign Permits, Building Permits) if the application is not the
owner.
I certify that notice of the application,
[County application name and number]
was provided 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
7Hand
identified below:
delivering a copy of the application to G
[Name of ilk 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 11111`15
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].
J)0 0 416
(:Ii�ggn�ature of Applicant
Print Applicant Name
Date