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HomeMy WebLinkAboutCLE201500234 Application 2015-12-21Application for Zo_ninClearance CLE # @Q A 5 — a�-� L-1 a.,• 'fir � OFFICE USE ONLY PLEASE REVIEW ALL 3 SHEETS Check # l "t" 1-o Date: f j Receipt # _ L% 341 �Z Staff: PARCEL INFORMATION CL Tax Map and Parcel: (3°7 000 0CC01 i q J Existingzoning CCI" M i. !! r .I Parcel Owner-��Ily /M ),_ 1J Parcel Address:_ _ I i Zq R i r m0 n City Chaf le, State l L Zip 22gQ (include suite or floor) PRIMARY CONTACT . Who should we call/write concerning this project? Address : 3 CW f City Roanoke- State Virginia— zi 'No! �i�i-}e- t02Office Phone: (.SDi L4 ©Q , [)5� Cell # 52-0 •10'iO Fax # 400. U30 F mail APPLICANT INFORMATION Check any that apply: L _Change of ownership Change of use iC Change of name New business Business Namerrype• _ 34vp -En ) };Io l -s-ks &'V �lYt Previous Business on this site (�V�o { 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: _ . Sam'. Q �q bosom n n 011a A3.❑tA- � *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 true and accurate to the bess knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them. Signature .� r�� Printed opus 1 urz) el - APPROVAL fAPPROVAL 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 L [ Zoning Official Date 0 z//�N� Other Oficial Date County of Albemarle Department of Community Development 401 McIntire Road Charlottesville, VA 22902 Voice: (434) 2%-5832 Fax: (434) 972-4126 Revised 7/1/2011 Page 2 of 3 Intake to complete the following: Reviewer to complete the following: Y /0 Square footage of Use, Is use m LI, HI or PDIP zoning? If so, give applicant a Certified Engineer's Report (CER) packet 6/ N YIN Permitted as: Will there be food preparation? Under Section: X22 -2-1 If so, give applicant a Health Department form: Zoning review can not begin until we receive approval from Health Supplementary regulations section: Dept. FAX DATE Circle the one that applies_, Is parcel on private well o n6lie water? Parking formula: /u ! If private well, provide Health Department form. _ tP Zoning review can not begin until we receive approval from Health Required spaces: Dept. FAX DATE Y/ Circle the one that applies Items to be verified in the field: Is parcel on septic pn&e sewer? Y 1 No Will you be putting up a new sign of any land? If so, obtain proper , Sigh permit. Permit # Inspector : Date: Y / N) Notes: Will there be any new construction or renovations? If so, obtain the proper Permit, Permit # Zoning to complete the following: Violations: Proffers: Y/ Y/O If so, st: if so, List: Variance: 6/N SP's: Y/� If so, List: If so, List: $ —Z 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 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] the owner of record of Tax Map and Parcel Number by delivering a copy of the application in the man er identified below: Hand delivering a copy of the application to N e. t [Name of thle 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_I I I Irl � I -- 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]. gnature of Appl . Siicanticant Print Applicant Name Date