HomeMy WebLinkAboutCLE201600034 Application 2016-02-24Application for Zonin Clearance
CLE # l� -
OFFICE USE ONLY
PLEASE REVIEW ALL 3 SHEETS Check # f0/C`p Date:
[Rece!Dt#)"- i / Staff:
PARCEL INFORMATION ad
Tax Map and Parcel: O 7i U 0 O Existing Zoning_ C
Parcel Owner: v Z,G ti WBS
Parcel Address: �'i%►r State Zip
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project?
Address • U r f City Cl?URd Mate Zip
Office Phone: L� Ce13# � � 2� -# E-mail SO I
APPLICANT INFOR OLON
Check any that apply: Change of ownership d -OOP' Cbange of use Change of name New business
Business Name/Type: C—Gt , - Wq
Previous Business on this site ' W C F
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: G . W P�-
*This Clearance will only be valid on the parcel for whicb 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 owners permission to use the space indicated on this application. I also certify that the information provided
is true and accurate. to the best of my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature Printed
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 `t
Zoning Official Date
Other Official Date
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902. Voice: (434) 296-5832 Fax: (434) 972-4126
�� ��� 1�1� ��r �� ���� �frvf� � /yRevised 11/1 /20 15 Page 2 of 3
Intake to complete the following:
Y 61
Is use in LI, M or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Yl
Will ere 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 o ub is waer?
If private well, provide Heal ent form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applies
Is parcel on septic 4r public sewer?%
YN
Wi u be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y
WIbe any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zonint: to complete the following:
Reviewer to complete the following:
Square footage of Use: —T _
/N
ermitted as.'� it W
Under Section: ?�
Supplementary regulations section:
Parking formul
Required spaces:
Y/N
Items to be verified in the field:
Inspector : Date:
:i !. • 1 Illi
I
Viola ns:
Y
If so, I ist:
proffers.
y /
If so"Mt:
Varia e:
Y/
If so, lst.
SP's:
Y19N
Ifs st:
Clearances:
SDP's
Revised 11/1/2015 Page 3 bf 3
E
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 or Appeals, Sign Permits, Building Permits) 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 to the following address:
Date'
[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
2Zze-
Date