HomeMy WebLinkAboutCLE201500235 Application 2015-12-21Application for Zoning Clearance
CLE #_aOtS a -S S-' `
OFFICE USE ONLY
PLEASE REVIEW ALL 3 SHEETS Check # l "L 'AO Date: t (j
Receipt # I OX 1 a staff.-
PARCEL INFORMATION
Tax Map and Parcel: O&tO L- 00 --00 -- b c) Existing Zoning
Parcel Owner:
Parcel Address:
TVv City 0 E ejn 'V', g State VA Zip
(include suite or floor)
PRIMARY CONTACT
Who should we call/nnwrite concerning this project? I h1 rnaSroer for i jV 2, -TT
Address City aaoLe— State VA zip ot/o1
Office Phone: (�L) qOO- 640 Cell 2 J QFax #&gQ0.0%Z E-mail f�U
s -up i � e>• a�
APPLICANT INFORMATION
Check any that apply: Change of ownership c Change of use _,Change of name New business
Business Name/Type: lrt i'
Previous Business on this site a d f
Describe the proposed business including use, number of employees, number if shifts, available parking spaces, number of
vehicles, and any additional information that you can provide: S ' # o'Z o S,�'P 3 e
"r, Sla--Lfaa
*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 cer* 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 true to to the best of my4mowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
SiKPrinted�� s1
APPROVAL INFORMATION
�Q Approved as proposed [ ] Approved with conditions [ ] Denied
[ ] Backflow prevention device and/or current test data needed for this site. Contact ACSA, 9774511, 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(
Zoning Official Date /4/Z Ll /S'
Other Official Date
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (434) 972-0126
Revised 7/1/2011 Page 2 of 3
Intake to complete the following:
Y /
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
YIN
iII there 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 wellu lic water?
If private well, provide He ent form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that appli
Is parcel on septi public sewer?
Y
W u be putting up a new sign of any kind? If so, obtain proper
Sign permit
Permit #
Y N
Wil ere be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
F,'Oning to complete the
Violate ns:
Y!
If so,—List:
Variance:
V1 N
If so, List:
Clearances:
Reviewer to complete the following:
Square footage of Use:
(9/N
Permitted as:
Under Section: � y Z l
Supplementary regulations section:
Parking formula: '4r— plqj
Required spaces:
Y/N
Items to be verified in the field:
Inspector : Date:
Notes:
Profie s:
Y/
If so, List:
SP's:
Y /ln
If so, List:
i
SDP's
2 17
-sy
Revised 7/1/2411 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
m er identified below:
Hand delivering a copy of the application to er Is I&A tj G
[Name of i& 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 II I1`111
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].
-Signature of Applicant
1 Ec2i;? [ A _
Print Applicant Name T
Date