HomeMy WebLinkAboutCLE201600050 Application 2016-03-09Application f r on` g Clearance
CLE # -
OFFICE
PLEASE REVIEW ALL 3 SHEETS Check # Date:
Receipt # Staff:
PARCEL INFORMATION
Tax Map and Parcel: -00- — Existing Zoning_
Parcel Owner: *
Parcel Address: 14y r*lbg%city) if 10, state VA Zip 221,E
(in de suite or oor)
PRIMARY CONTACT
Who should we call/write concerning this project? G
Address: ' -,W �• City State !wo\ 7,ip 12=
Offfce Phone: X90_} f0°I1-•bJho Celi # .'102 Fax # '(ia• IaHt•�3o2 E-mail rwi 51Go�lItlSP.rth
APPLICANT INFORMATION
Check any that apply; Change of ownership Change of use Change of nameNew business
Business NamelType:/��&mSo ro
Previous Business on this site
Describe the proposed business including use, number of employees, n tuber of sh its, available parking spates, number o
vehicles, and any additional ' formation that you can provide: ?.o j
ZIIm tw. s„ a
*ibis 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 tha or ave th owner's permission to use the space indicated on this application. I also certify that the information provided
is true and accura the of knowledge. I have read the conditions of approval, nd I understand them, and that I will abide by them.
Signature Mnted I�Z7_ _..
.,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, x117.
[ ] No physical site inspection has been done for this clearance. Therefore, it is not a determination of compliance with the existing
site pian.
[ ] This site complies with the site plan as of this date.
Notes:
Building OfficialDate
Zoning Official .p `�lli` Date
Other Ofiilcial Date
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (434) 972-4126
Revised 7/1/2011 Page 2 of
Intake to complete the following:
yo
Is use in LI, HI or PDIP zoning?
Engineer's Report (CER) packet.
If so, give applicant a Certified
Y/1
Will t 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 i0falbZlErW10
e
If private well, provide H ent form.
Zoning review cannot begin until we receive approval from Health
Dept. FAX DATE
Circle the one that appl'
Is parcel on septic or sewer?
YIN
Will you be putting up a new sign of any kind?
Sign permit.
Permit #
If so, obtain proper I
Y/N
Will there be any new construction or renovations?
If so, obta
Permit #'
Reviewer to complete the following;
Square footage of Use: 3 d
IN e4
.Permitted as: i
P
Under Section: -2- (-. -L.. t
Supplementary regulations section:
Parking formula: y�
Required spaces:
/S
YIN
Items to be verified in the field:
Inspector :
Notes:
Date:
zoning to complete the fallowing:
[—Violations: offers:
Y I (3� / N
If so',ist: If so, List:
Varla ce:
Yl Yl
Ifs , est: Ifso, st:
Clearances: SDP's
Revised 7/1/2011 Page 3 of3
CERTIFICATION THAT NOTICE OF THE
APPLICATION HAS BEEN PROVIDED TO THE LANDOWNER
Thisform 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,
[County application name and number]
ft
was provided to e, 0 IQ the owner of record. of Tax Map
[name(s) of the Irecord owners of the parcel]
and Parcel Number
manner identified below:
delivering a copy of the application in the
—A Hand delivering a copy of the application to Lmie, Fuxn of Q 4616
Name of the Acord 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
taddress; written notice trailed 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 ssment records satisfies
this requirement].
Signature of Applicant
Vtut L44
Print Applicant Name
1-1
Date