HomeMy WebLinkAboutCLE201600089 Application 2016-04-26Application for Zoning Clearance
OFFICE USE ON
PLEASE REVIEW ALL 3 SHEETS Check # a Y
Date: I 11
Receipt # staff..
PARCEL INFORMATION �n
Tax Map and Parcel: ij to®� Existing Zoning.Pi f d
Parcel Owner- �
Parcel Address:" City State Zip
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project9 f r
Address : - o a&Acity State V A— Zip?2
S C,� Clio
Office Phone: Cell #4ax E-mall
e 694
CS
APPLICANT INFORMATION
Check any that apply. Change of ownership Change of use Change of name New business
Business Nam yp : (—K
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: JL",V-0
*This Clearance will only be valid on the parcel for which it is approved. Ifyou change, intensify or move the use to anew 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 acTvate 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
APPROVAL INFORMATION
Approved as proposed [ ] Approved with conditions [ ] Denied
[ ] Backilow 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 r1 Date (� I zx. C
----
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 HA/2015 Page 2 of 3
Intake to complete the following:
Y1
Is usZrin LI, HI or PDIP zoning?
If so, give applicant a Certified
Reviewer to complete the following: lj
Square footage of Use: Lot
Engineer's Report (CER) packet. / N
ermitted as: Q S
Y /�l�
W it ere be food preparation? Under Section:
If so, give applicant a Health Department form,
Zoning review can not begin until we receive approval from Health Supplementary regulations section:
Dept. FAX DATE
Circle the one that appje
'
Is parcel on private w�o�r public ater?
If private well, providea epartment form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE_
Circle the one that
Is parcel on septic or or ublic sewe
Y TA
Will you be putting up a new sign of any kind?
Sign permit.
Permit #
If so, obtain proper I
Y 1
Will ere be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the following:
Parking formula: '�2 14
Required spaces:
YI
Items to be verified in the field:
Inspector
Notes:
Date:
Violations:
Y /
If so, ist:
Pro
Y /��
If so, List:
Vari e:
Y/
If so, List:
Y/
If so, ist:
Clearances:
SDP's
Revised 11/l/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, C4,vi -FAw44
[County al§plication r&e and number]
was provided to
[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 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 6wner 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 6 f _Z0 IP to the following address:
Date/
[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
�_ -i
Print Applicant Name
Date