HomeMy WebLinkAboutCLE201600001 Application 2016-01-07Application for Zoning Clearance
CLE #
OFFICE E QlqLY
PLEASE REVIEW ALL 3 SHEETS Check # Date: 1�
Receipt # staff.•
PARCEL INFOR T N Ll
Tax Map and Parcel: - Existing Zoning
Parcel Owner: Prop c
Parcel Address: � +1�(�� _fiver` Ci .'! State ZiP77
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project?Afi�emawd )4_L=J
Address
:11 0(3 5esl % /t-0leN�fi'cY/ City�•��...r t�`@ State �S � ..._ zip
Office Phone:"
Cell # 3ox -mail
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name/Type: V
Previous Business on this sitew 1/
Describe the proposed business including use, number of employees, tuber of shifts, available parking spaces, number of
v ices, any additional information that you can provid p
t<Avnwj
'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 be of my owledge. I have read the conditions of approval, and I understand then, and that I will abide by them.
Signature rd Printed_ Mg k Wi A d A
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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, xl 17.
[ ] 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
Zoning Official Date��zv/�
Other Official Date
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (434) 972-4126
Revised 11/1/2015 Page 2 of
-CaU•<+r%
Intake to complete the following:
Y 16
Is use in LI, HIor PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y /a
Will 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 well or u er?
If private well, provide Heal apartment form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applies
Is parcel on septic or j;t9li�r?
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
YIN
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zonine to complete the followine:
Reviewer to complete the following:
Square footage of Use:
Permitted as: f c' t
Under Section: "' '— • /
Supplementary regulations section:
Parking formula: I 2�
Required spaces: I
Y/W
Items to be verified in the field:
Inspector • Date:
Notes:
Violations:
SD/N
If so, List: � -
Proff rs:
Yl
If so, List:
_
Variance:
&/N
If so, List:
SP's:
Y/3CI�
If so, ist:
y2�
Clearances:
SDP's
Revised 11/1/2015 Page 3 bf 3
CERTIFICATION THAT NOTICE OF THE
APPLICATION HAS BEEN PROVIDED TO THE LANDOWNER
This form must accompany zoning applications (Home occupation, Zoning aearance, Zoning
Administrator Determinations orAppeals, Sign Permits, Building Permits) if the application is not the
owner.
1 certify that notice of the application,
was provided to
[County application name and number]
[name(s) of the record owners of the parcel]
and Parcel Number
manner identified below:
the owner of record of Tax Map
by delivering a copy of the application in the
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].
Signature of Applicant
Print Applicant Name
Date
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