HomeMy WebLinkAboutCLE201600043 Application 2016-03-07Application for Zoning Clearance
OFFICE US ON Y '
PLEASE REVIEW ALL 3 SHEETS Check # Date: C�- /
ii Receipt # _/d 338-1 Staff:
PARCEL INFORMATION j
Tax Map and Parcel: 6 O - C7A- Existing Zoning G�/ �y�ali f Ke -1 f L
Parcel Owner: (Y)J-)
Parcel Address: %9.> - 01 C City �l,A 6 c State U� Zip
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project?
Address: @ d City �� 1�, \,'� State `4 ,`� (92 zip
Office Phone: ( Cell # Lt-3�ii ;St#Z# E-mail.
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name/Type:V__ __S
Previous Business on this site
Describe the proposed business including use, number of employees, nufnher of shifts, available par ng spaces, number of
vehicles, and any additional information that you can provide: CE-, 0, a �- a 1�
*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 t�he space indicated on this application. I also certify that the ' rmation provided
is true and accurate. to the best of my knowledge. I havtions of approval, and I understand them, and that I wit] abi by them.
gnature Printed '� -i•
APPROVAL INFORMATION
'Approved as proposed [ ] Approved with conditions j ] Denied
] Backflow prevention device and/or current test data needed for this site. Contact ACSA, 977-4511, x117.
[ I 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— -at( ( r (
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
Revised 11/1/2015 Page 2 of 3
Intake to complete the following:
Y
Is use'in LI, M or PDIP zoning? If so, give, applicant a Certified
Engineer's Report (CER) packet.
Y /@
Will there 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 or.Awater?
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 appblic sewlies
Is parcel on septic or puer
Y:f N
WX you be putting up a new sign of any kind?
Sign permit.
Permit #
If so, obtain proper j
Y /(9)
Will there 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: '3
6) / N
Permitted as:
Under Section:
Supplementary regulations section:
Parking formula:
Required spaces:
Items to be verified in the field:
Inspector:
Notes:
Date:
Violations:
Y/
If So,ist;
Proffers:
Y/(N�
If so, rst:
Varia ce:
Y/
If so, ist:
SP,s•
Y/T
If so, List:
Clearances:
SDP's
Revised I l/1/2015 Page 3 bf 3
CERTIFICATION THAT NOTICE OF THE
APPLICATION HAS BEEN PROVIDED TO THE LANDOWNER
This form must accompany zoning applications (Home Occupation, Zoning awrance, Zoning
Administrator Determinations orAppeals, Sign Permits, Building Permits) if the application is not the
owner.
I certify that notice of the application, L / -- 1-75
�[County application name and number]
was provided to '`f') p ?'lam the owner of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number 0Cp/tjo -eV1fCPQ0 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].
ISiof Applicant
Print Applicarlt Name
C9 -SCA i G
Date