HomeMy WebLinkAboutCLE201600024 Application 2016-02-19Application for Zonini Clearance
CLE # `Q Q I (o — R
PLEASE REVIEW ALL 3 SHEETS
PARCEL INFORMATION
Tax Map and PaMel: —IS , 4g A
Owner:
i1]
OFFICE USE ONLY
Check # 1 234 Date: 0- 15
Receipt # 10 BID) 3 Staff. EF -4 -
Existing Zoning_ �A C -
Address: 27. c0VkVA0 ici City C e/d �f to
(include suite or floor)
zip G Z f j)
'I'R[MARY CONTACT k'
Who should we call/write concerning this rix pro's ? '(6 /
e7 e
Address:--7
kG o.M Ci 5toteV zipC�
Office Phone: 1'% Zell # �SI� Fax # E-mail d lrOJ Nt�c
APPLICANT INFORMATION
Check any that apply: / Change of ownership Change of use Change of name New business
Business NamelType: oett�(S"V, ii (C�.� ✓1 � �~
Previous Business on this site C k P -e— 1' (
Describe the proposed business including use, number of employees, number of shifts, available parking spaces, number of
ve icles a any additional f�formation t you can provide: _� IK
C�4C CaA'�Ykc A ^, T r/1 CP, . I :- 0- li
*T11is 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 the space indicated on this application. I also certify that the information provided
is true and accurate. to th y knowledge. I have the conditions of appro and I understand them, and that I will abide by them.
Signature
Printed ti,�
APPROVALOCF0RMAZcVor
Approved as proposed A roved with conditions
[ ] pp [ ]Denied
[ ] Backflow prevention deviceurrent 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 Z)—
Zoning Official Date JIU6
Other Oficial 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
1/'
cov"
Intake to complete the following:
Y/N
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y
Wia 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 lies
Is parcel oK�private w r public water?
If private wel , provide Health Department form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the on applies
Is parcel septic o public sewer?
YIN
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Reviewer to complete the following:
Square footage of Use: L—cJL)
(9 / N
Permitted as: I.A4 Qi '� c ez/'✓��-'
Under Section:
Supplementary regulations section:
Parking formula:
Required spaces: L,,,�
Y/N '�
Items to be verified in the field:
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:
Y/A
If so"List:
pro
Y/ .
If so, List:
Vari ce:
Y/
If so, List:
SP's:
Y/
If so, st:
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 appilcations (Home Occupation, Zoning Clearance, Zoning
Administrator Determinations or Appeals, Sign Permits, Building Permits) ifthe application is not the
owner.
I certify that notice of the application,
[County application name and number]
was provided to � r kvy\,-J &jAde-,ML-L-61--'
the owner of record of Tax Map
4name(s) of the record owners of the parcel]
and Parcel Number by delivering a copy of the application in the
manner identified below:
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].
Of
Zf/
Print Applicant Name
Date