HomeMy WebLinkAboutCLE201600069 Application 2016-04-05Application foirZoiling Clearance
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OFFICE Y
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PLEASE REVIEW ALL 3 SHEETS Check# late:
Receipt # staff:
PARCEL INFORMATION
Tax Map and Parcel: Existing Zoning
Parcel Owner: -5' sneAgr 5W.'a) VEj!ru&eS a,(- ..---
Parcel Address:.250 AIAPA N89Tl AU!:i 4V& . City4* Lo �t State VA ZipM62-
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project? DA N TUGIr
Address : a SW 69e&2 SERE& ,-U i� City M090 9--tJ State. 615017&M Zip 30Z1?
Office Phone: 770 -49Z - 9 Soo Celt #f KW-.1YC- i�lo7 Fax # 770-1C9Z-870Z Email q�►N��aw�e sail �iN
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name =jNew business
Business NomeiType; MT alp -47
Previous Business on this site /fOSTL'%
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: 1, Z54,,4. 60C, 4!�!CZCAr,1ElW
*This Clearance will only be valid on the parcel fbr, which it is approved. If you change, intensify or move the use to a new location, anew 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 ro e best of my knowledge. I have read the conditions of approval, and 1 understandd therm, and that I will abide by them;
Signature Gt/ Printed T I nOTN Y C^..�L✓�r.c. t S
APPROVAL 110ORMATION
Approved as proposed [ ] Approved with conditions ] Denied
[ ] Backflow prevention device and/or current test data needed far this site, Contact ACSA, 977-4511, x117.
[ j No physical site inspection has been. done far 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
Zoning Official 1A Date'6k� � V �
Z✓
Other Official Date
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5932 Fax: (434) 972-4126
Revised 1 I/1/2015 Page 2 of 3
Intake to complete the following:
Y l
Is use LI, HI 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 lie r?
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 Lse O
YIN
Will you 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: __ / 1 _
(5 / N
Permitted as: %, b t4, /
Under Section: _ 7S,4. Z- `
Supplementary regulations section:
Parking formula:
Required spaces: -6
Y
Items o be verified in the field:
Inspector : Date:
Notes:
Violat• ns:
Y/l}1'
If so, ist:
rollers:
/N
If so, List:
Varian e:
Y /
If so, List:
SP's•
Y / I+
If so, List:
Clearances:
SDP's
Revised 11/1/2015 Page 3 of 3
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 tile 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
Print Applicant Name
Date