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HomeMy WebLinkAboutCLE201600010 Application 2016-01-28FApplication for Zoning Clearance CLE #J6 Kv 6o n I a OFFICE US����ONL PLEASE REVIEW ALL 3 SHEETS Check# -�/ 5 Date• Receipt # 75 Anc, staff;' PARCEL INFORMATION Tax Map and Parcel: ©.,� 00 -- a ,n '- Existing Zoning C At Parcel Owner: Parcel Address:. ne City � State Vii Zip T4 (include suite or floor) a PRIMARY CONTACT Who should we call/write concerning this project?Ile �2ai Address : City State p Office Phone: (93.�) -'ytJ _tntpc•zS_ Cell # Y, -. i49 -g33 Jax #i E-mail i ]�''t y�l(z �� • l�� APPLICANT INFORMATION Check any that apply: Change of ownership Change of use Cbnnge of name 9bursmoss Business Name/Type: �i � • � Previous Business on this site Describe the proposed business including use, number of employees, number of shifts, available parking spacvehicles, and any additional information that you can provide: Nin l - `� , 4 ri; Woi:jg. :' •�. *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 aCCUrr to best of my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them. Signature Printed�� t APPROVAL INFORMATION $Approved as proposed [ ] Approved with conditions [ ] Denied [ ] Backflow prevention device and/or current test data needed for this site. Contact ACSA, 977-45I 1, 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 i 1ta ao l b Zoning Official Date 'Z 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 3 Intake to complete the following: Reviewer to complete the following: Y & N Square footage of Use: 150 t) Is u3e'm LI, HI or PDIP zoning? If so, give. applicant a Certified Engineer's Report (CER) packet. 6/ N / Permitted as: Y Will ere be food preparation? Under Section: 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 or wbiic water's If private well, provide Health epartment farm. Zoning review can not begin until we receive approval from Health Dept. FAX DATE Circle the one that a Is parcel on septicpublic sew Y (/ N p Wi u be putting u a new sign of an kind? If so obtain proper P g Y P P Sign permit. Permit # Y ,�N W� ere be any new construction or renovations? If so, obtain the proper Permit. Permit # Zonine to complete the following: Parking formula: - - - 4k �.. Required spaces: T to be verified in the field: Inspector • Date: Notes: Violations: Proffers: �IN (3/N If so, List: If so, List: ALAS Variance: SP's: 0/N J)/N If so, List- If so, List: Clearances: SDP's Revised 11/1/2015 Page 3 bf3 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, Gj.L t� /�, W &06 /0 [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 manner identified below: by delivering a copy of the application in the Hand delivering a copy of the application to j11 l c d Lmac [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]. — J, A-�� Sign of p caITrn Print Applicant Name Date