HomeMy WebLinkAboutCLE201500128 Application 2016-03-28Application for Zonin Clearance:A`
CLE #�a
PLEASE REVIEW ALL 3 SHEETS
OFFICE US O Y
Check# to`m Date:IAA, Of s--
Receipt # 0 1 Staff:
PARCEL INFORMATION , f
Tax Map and Parcel: oC, [ oo - o p p a a t ooco Existing Zoning
Parcel Owner: (%0 VI f kI
Parcel Address: /90 11J plX-S City State Y. Zip
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project?
Address:��'t% 101O�rASf Ci�{'f0 �i State_�a ZiplvO�
Office Phone:(o U "Cell # Sarn P- Fax # E-mail kRly sa. C)
APPLICANT INFORMATION
Check any that apply: Changeof ownership Change of use Change of name New business
Business Name/Type: U
l [/IQ d
Previous Business on this site no iii el
Describe the proposed business including use, number of employees, number of shifts, available parking spaces, number of
vehicles, anr� any additional information tl}at you can provide: 0 )*LrMVL n 1-E—ti
*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.
1 hereby certify that I own or have the owner's permission to use the space indicated on this application. I also certify that the inf, ation provided
is true and to t best cno e. I have read the conditions of approval, and I understand the wI ab' a by them.
Signature Printed ! >i
APPROVAL INFORMATION
[ ] Approved as proposed [ ] Approved h conditions [016enied
[ ] 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 plan.
[ )This site complies with the site plan as of this date.
Notes:
Building Official
Zoning Official
Other Official
Date
Date
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 3
MR
Intake to complete the following:
Is
Is LO LI, HT or PDTP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
YIN
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
_
Circle the one that applies
Is parcel on private well or public 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 septic or public sewer?
YIN
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
YIN
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:
YIN
Permitted as:
Under Section:
Supplementary regulations section:
Parking formula:
Required spaces:
YIN
Items to be verified in the field:
Inspector: Date:
Notes:
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Vio 'ons:
Y1
Ifs st:
ProffeN
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If so,List:
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SP's:
Y /A
If s0%,,-15 st:
Clearances��[o �
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SDP's
Revised 7/1/2011 Page 3 of 3
CERTIFICATION THAT NOTICE OFTHE
APPLICATION HAS BEEN PROVIDED TO E LANDOWNER
This form must accompany zoning applications (Home Occupation, ning Clearance, Zoning
Administrator Determinations or Appeals, Sign Permits, Building ermits) if the application is not the
owner.
I certify that notice of the application,
was proviae4
[name
and Parcel Number
manner identified Belo
Nand delivering
application name and number]
the owner of record of Tax Map
of the record ownersoft parcel]
by delivering a copy of the application in the
of the
person; if the owner V record is
title or office for that 4tityl ,
on
Date
Mailing a copy of theY"an
li
if the owner of record
office for that entity]
on
Date
�Ation to
[Name of the record owner if the record owner is a
entity, identify the recipient of the record and the recipient's
to
[Name of the record owner if the record owner is a person;
identify the recipient of the record and the recipient's title or
to the following address:
[address; written otice mailed to the o er at the last known address of the owner as shown on
the current realtate tax assessment boo or current real estate tax assessment records satisfies
this requirement
Signature of Applicant
Print Applicant Name
Date