HomeMy WebLinkAboutCLE201600090 Application 2016-04-26Application for Zonine Clearance
CLE # 82r
oFFI usE o
PLEASE REVIEW ALL 3 SHEETS Check # to Date:))b
Receipt # Staff: — {2
PARCEL INFORMATION fb
Y'�
Tax Map and Parcel: 'r f Existing Z0nm;Kh9fl
Parcel Owner• AM LCkA U I V t 0M
Parcel Address: L*yoffl�'el'ae?l R City State im Zi
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project?
Address • City State Zi
Cf j
Office Phone: � I Cell # Fax # E-mail
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business NameJType: T,* r lua
Previous Business on this site
Describe the proposed business including an, number of employ , n b ailable king , number of
vehicles, and any additional inf tion that you provide:
*This Clearance will only be valid on the parcel for which it is apprbved. 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 owners permission to use the space indicated on this application. I also certify that the information provid
is true a to best of my know/ ge. have read the conditions of approval, and I understand them, and that I bide b
Signature aJ U
Printed p Cis'
APPROVAL INFORMATION
Approved as proposed [ ] Approved with conditions [ ] Denied
[ ] Baclflow 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 Date q f(")-
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 11/02/2015 Page 2 of 3
Intake to complete the following:
Y l
Is uQtLI, HI or PDIP zoning?
Engineer's Report (CER) packet.
If so, give applicant a Certified
Y /
Will re�j
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 a lies
Is parcel o rivate well r public water?
If private weir,prove a Health Department form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the orwakt applies
Is parcel ok5wor 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:
19
re N
ermitted as: 4j/QAJ ;%AfeY)%;tYJ,�
Under Section:
Supplementary regulations section:
Parking formula:
Required spaces:
YI
Items to be verified in the field:
Inspector : Date:
Notes:
Violations:
Y/2
If so, st:
Proffers:
Y/C5f
If so, List:
Variance:
Y /AT
If so, st:
SP's•
Y /�
If so, last:
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, u 6T Vf, i&w !�fw
[County application name and number]
was provided toW-M& iJIME OM& the owner of record of Tax Map
[name(s) of the record owners of the parcefF
and Parcel Number r7 by delivering a copy of the application in the
manner identified below:
Hand delivering a copy of the application to ��dLLJ9]�L��
k
[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
Q 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].
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Print ApplicantNainjo,
Date
KESWICK HORSE SHONN G R OUNI DS
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