HomeMy WebLinkAboutCLE201600009 Application 2016-01-28Application for Zoning Clearance A
CLE # AG14- eL!;)66
F
OFFICE USE ONLY
PLEASE REVIEW ALL 3 SHEETS Check # 49,6x9 Date:
Receipt # /Ga '7'163 Staff:
PARCEL INFORMATION
Tax Map and Parcel: 2 / / -7 F 2% Existing Zoning_' _
Parcel Owner: _P% F LL t,
Parcel Address: 31 0 -- Do � I0 AaVAJ city State �7
• Ci Zip
(include suite or floor)
PRIMARY CONTACT
Who should we cali/write concerning this pro ject?//t� Yt'
Address :5 165 r�9 Qui v,._ Or city C3go3yWiLkk State As9Qq! I .
Zip
Office Phone: EN dell # 11 Fax # E-mail L a3c�1�5 5�
APPLICANT INF TION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name/Type; { J(� Y� 1.� �l[,li� Q(�QI'le i�Y fY[iiti �� !r f Ani i ��� r wrL �_�.•
Previous Business on this site r i 1 -Cr, rr-kwl„M n d +i In f lnA 1rn NdJ nn A
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:
*This Clearance will only be valid on the parcel for which it is approved. Ifyou 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 best o y knowledge. I have read the conditions of approval, and I understand them, and that I will abides by them.
Si re
AIWROV4L INFORMATION
A'�prKed 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
Zoning Official Date y
Other Official
Date
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (434) 9724126
Revised 11/1/2015 Page 2 of 3
Intake to complete the following:
Y/N
Is use i I or PDIP zoning? If so, give applicant a Certified
Engineers eport (CER) packet. e
Y N"�''
Will be food preparation?
If so, give applicant a Health Department form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DA'Z'E
Circle the one that applies
Is parcel on private well or ublic water?
If private well, provide 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 septic or u 1 c s
Y/
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Pe #�-
r
N
ere be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
ZoninEr to complete the followinLr:
Reviewer to complete the following:
Square footage of Use:. K7.576
el N 'a
Permitted as: rRG e,r
�
Under Section: . ?—. ,a
Supplementary regulations section:
Parking formula: f
Required spaces:
YI Iq
Items a verified in the field:
Inspector • Date:
Notes:
Viola 'ons:
Yl
pro
If so, List:
If oist:
Variance:
SP's•
Y /6
Y /
If so, List:
If so, List:
Clearances:
SDP's
,67P =,
Revised 11/1/2015 Page 3 of 3
C.,
CERTIFICATION THAT NOTICE OF THE
APPLICATION HAS BEEN PROVIDED TO THE LANDOWNER
This form must accompany zoning applications (Hoene Qcmpa&n, Zoning Clearance, Zoning
Administrator Determinations orAppeals, Sign Permits, Building pennits) 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]
and Parcel Number
manner identified below:
Hand delivering a copy of the application to
the owner of record of Tax Map
by delivering a copy of the application in the
[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