HomeMy WebLinkAboutCLE201600105 Application 2016-05-04Application for Zoning Clearance
CLE # 201i9'1 05
OFFICE USE ONLY
PLEASE REVIEW ALL 3 SHEETS Check # 1111 Date: #ja91jL0
Receipt # _104 Staff: Fi2L
PARCEL INFORMATION
Tax Map and Parcel: —71? - I t Existing ZoningLV
Parcel Owner: fk 1 b4sm'n-r le
Parcel Address: B City C/1us'su1(c' State VA Zip11
(include suite or floor) tLamn 0,, {`)6*
PRIMARY CONTACT Who should we call/write concerning this project? Lk, GM I r
Address: SL4 ..:tilt UV,-Q City State Zip 2,7
Office Phone: 0134) ZZ �- `�30SCe Fax # E-mail �' �' �+ u"` 1' can
APPLICANT INFORMATION
Check any that apply: p Change of ownership Change of use Change of name ✓ New business
L-- Business Name/Type: i t t C " 1 � / WjfA.S'S4� � +t%,.
Previous Business on this site
Describe the proposed business including use, number of employees, number of shifts, ava' able parking spaces, number of
vehicles, and any additions information that you can provide: fill -.-P, 6 5 -
*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.
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 to the
J best of my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature _� _ Printed J I
APPROVAL INFORMATION
1>4 Approved as proposed [ ] Approved with conditions [ ] Denied
[ ] Backflow prevention device and/or current test data needed fnr 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 S 13 C
Zoning Official Date -4/2y
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/l/2015 Page 2 of 3
Intake to complete the following:
04,
Z
Is usK LI, HI or PDIP zoning?
Engineer's Report (CER) packet.
If so, give applicant a Certified
Y
Wi 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 ubli at
If private well, provide Health Departm in.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that appl'
Is parcel on septic o pWt W e .
Y
Wi you be putting up a new sign of any kind? if so, obtain proper
Sign permit,
Permit #
Y
Wil 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: / 3 1
O/N
Permitted as:� LQ-
Under Section:
Supplementary regulations section:
Parking formula: LOJ
Required spaces:
YI61
Items to be verified in the field:
Inspector : Date:
Notes:
Viol tions:
Y1 1
If so, List:
Proffers:
Y/&
If so, List:
Variance:
Y /
If so -Mist:
SP's:
Y I
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 orAppeals, 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:
the owner of record of Tax Map
by delivering a copy of the application in the
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].
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Sig1na�ture of Applicant
G i 1, l
Print Applicant Name
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Date a
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