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HomeMy WebLinkAboutCLE201600036 Application 2016-02-24;J0 (te �1��S PIo,� 3,�k Q� t���E l �X Application for Zoning Clearance CLE # ! 0 OFFICE USE ONLY PLEASE REVIEW ALL 3 SHEETS Check# Date: Receipt # !b/ Staff: PARCEL INFORMATION Tax Map and Parcel: Parcel Parcel Address:t � © 1_L7 City (include suite or boor) Existing Zoning 6 Yo— Zip PRIMARY CONTACT Who should we a ccall/write concerning this project?P Address _ � \ :T 0 � City 4 6' �ta�te� ` �� Zip Office Phone: LLzd L,✓ d q#73 -(J 'Cell # `• q(V - h �ax # qq3 - I l e-mail APPLICANT INFORMATION Check any that apply: Change of Business Name/I'ype:'-,.JJ(3 Previous Business on this site of use Change of name ' New business S -t Clearance will be required. ,uccnbuy ur muve me use w a new iocauon, a new "zoning T hereby cern at tify I own or have the owner's permission to use the space indicated on this application. I also certhat the information provided is true and urs to the bestlof my 4TUge. I have read the conditions of appro ;-nd understand them, and apI will abide by them. Signature Printed 1 „E4 I APPROVAL INFORMATION X Approved as proposed [ ] Approved with conditions [ ] Denied [ ] Backflow prevention device and/or current test data needed for this site. Contact ACSA, 977-4511, x117. [ j 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 t 3 Zoning Official Date ?lam f 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 in LI, HI or PDIP zoning? If so, give applicant a Certified Engineer's Report (CER) packet. Y I�Wil 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 oru lie 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 septico blic sew YIN Will you be putting up a new sign of any kind? If so, obtain proper Sign permit. . /%j o Permit # Y Wi ere be any new construction or renovations? If so, obtain the proper Permit. Permit # Zoning to complete the following: Reviewer to complete the following: Square footage of Use: O 1 N nn Permitted as; Under Section: Supplementary regulations section: Parking formula./ Required spaces: YI Items 0 be verified in the field: Inspector : Date: Notes: Violations: Y/1g If so, -List: Proffers: Y/q If so,it: Variance: If / If so, ist: SP's-; I fs , ist: Clearances: SDP's Revised 11/1/2015 Page 3 of 3 CERTIFICATION THAT NOTICE OF THE APPLICATION HAS BEEN PROVIDED TO THE LANDOWNER This form must accompany coning applications (Home Occupation, Zoning Ckarance, Zoning Administrator Determinations or Appeals, Sign Permits, Building Permits) if the application is not the owner. I certify that notice of the application, [County application name and number] was provided to the owner of record of Tax Map names) of the record owners of the parcel] and Parcel Number delivering a copy of the application in the manner identified below: Hand deliveringa co of the ligation toylmo Lc-�A- copy app sine 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] tt on f / 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]. �t s Sip -nature of Applicant F, (�k Vii! s P Ap licant N e 10 a� Date