HomeMy WebLinkAboutCLE201500184 Application 2016-04-09{lY ni
Application for Zonin Clearance �'`
CLE # \ 1 �'
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OFFICE USE ONLY
PLEASE REVIEW ALL 3 SHEETS Check # Cc� Date:
Receipt # 0 Staff:
PARCEL INFORMATI N
Tax Map and Parcel: l - J /T Existing Zoning IV hbuf h IJs
Parcel Owner: Qoh
Parcel Address: 0 41 is City Statey1 zipd0
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project?
Address: 0 ih City State Zip
Office Phone: Cqj` T? b5' 1,j Cell # W-`3�!-F Fax # E-mail J::�&
APPLICANT INFORMATION
Check any that apply: � Change of ownership Change of use Change of name New business
Business Name/Type: L -C
Previous Business on this site L c j s 3 S LLL —
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:
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*This Clearance will only be valid on the parcel for which it is approved. If you change, intensify or move the use to anew 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 the best of m owledge. I have read the conditions of approval, and I understtaand� ahem, and that 1 will abide by them.
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Signature Printed
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 plan.
[ ] This site complies with the site plan as of this date.
Notes:
�- _ i t
Building Official Date
Zoning Official DateI<�
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 7/l/2011 Page 2 of 3
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Intake to complete the following:
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Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
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ill there be food preparation?
If so, give applicant a Health Department form.
Zoning review can not be m until we receive approval from Health
Dept. FAX DATE _ Lg11taL<—
Circle the one that applies
Is parcel on private well or vb,ter?
Ifprivate well, provide Health epartment form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applies
Is parcel on septic ore'
Reviewer to complete the following:
Square footage of Use: 3 1--11lo
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Permitted as: , M
Under Section: ���� G C • b�
Supplementary regulations section:
Parking formula: y,
7 a®�
Required spaces: /5
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Items to be verified in the field:
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Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit. Inspector : Date:
Permit #
Notes:
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Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
ZoninLy to complete the following:
Viola ions:
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If so, List:
Proffers:
IN
If so, List: 6�3�
41—
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If so, List:
Variance:
(2) /N
If so, List:
SDP's p 6gp
Clearances:
Revised 7/1/201 1 Page 3 of 3
CERTIFICATION THAT NOTICE OF THE
APPLICATION HAS BEEN PROVIDED TO THE LANDOWNER
This form must accompany zoning applications (Horne Occupation, Zoning Clearance, Zoning
Administrator Determinations or Appeals, Sign Permits, Building Permits) if the application is not the
owner.
l 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:
the' owner of record of Tax Map
delivering a copy of the application in the
V 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].
ASigg-natureplicant
PrimApplican Name
n
Date
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