HomeMy WebLinkAboutCLE201600030 Application 2016-03-14Application for Zoning Clearance
CLE #
OFFICE USE ONLY
PLEASE REVIEW ALL 3 SHEETS Check # 10 90 Date:d1` ��� ' _.1�70/0
PARCEL INFORMATION Receipt # .o3 /tea _ $teff: ,cL,�
Tax Map and Parcel: !j a� �E�1O- 0.. -• QW- O_ p t1 _ Existing Zoning10"
Parcel Owner: '� 1G
Parcel Address:_ " > City State
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning � this project?
Address: p� 'Loneity `V State Zip
Office Phone: `A(!i Ceu# 43914Rx#�
E-mail. I";1SeY7S N+a fry i•, r ,
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Namefrype: r
Previous Business on this site
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:
*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 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 FOW t d-1 4 D t-Vt S --\J
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 _ it
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
IFMA
Intake to complete the following:
Y l2V C'1-CP17V'1A1
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
�E,n�gineer's Report (CER) packet.
� N
Will there be food preparation? A�/
If so, give applicant a Health Department form. V
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
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 septic o ublic sewe .
.r%
VN
Iyou be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y) N
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: = 2 t7y _
(�)/N
Permitted as; &13 z6ore
Under Section:
Supplementary regulations section:
Parking formula:
a > a
Required spaces:
Y / P1)
Itemrto be verified in the field:
Inspector • Date:
Notes:
Violations:
Y
If so, List:
Pratt rs:
Yl
If so, ist:
Varia,,n+ge:
Y/�1/
If so, List:
SP's•
Y/(��
If so,'Isist.
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 mug accompany zoning applications (Home Occupation, Zoning Clearance, Zoning
Administrator Delerminatlons orAppeals, 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
[name(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].
Signature of Applicant
nw {W °"4 �
Print Applicant Name
Date
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