HomeMy WebLinkAboutCLE201600109 Application 2016-05-04Mee
CLE R.
PLEASE REVIEW ALL 3 SHEETS
Clreck# 1 Rate:
Receipt # Stan --
PARCEL
Taxi 1VJ[ap and Pa ret !: [ T$C�� _. ���
C �
� i� i'� Existing Zoning__C
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ParcelOwner: lV z3e L '�C'`-
Parcel Address: "
3✓t I � te
City�Y '1f1ti-
(include suite or floor)
PRIMARY CC3TITACT
W should we call/write. concerning this project? f 4 rt
] �_ 'pif:RIkStr€#e
Address :1'r)
City 'c,�s,
Office Phone: OD Cell #
Fax # � ` -Iris , �
APPLICANT INFOJ+IATION
Cheek any that apply; Chan a oft wnersh'
Change of use Change of name l+7ew
l usine3a
Previous Business on this site
Clearance will be rr quind.
I hereby certify that I r ha owaees pe lesion to use icated an this application. I also certify that the information provided
Is true and accur t y 1^ I have read @vns of approval, and I understand them, and that I will abide by them.
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Approved as proposed [ I Approved with conditions [ ] Denied
] Backflow prevention device and/or current test data needed for this site. Contact ACSA, 9774511, x117.
[ ] No physical site inspection has been done for this clearance. Wherefore, it is not a determination of compliance with the existing
site plan.
[ ] This site complies with the site plan as of this date.
Notes"
Date
Date _�S�y�z4��
County of Allreraarle Department of Community Development
401 Mdntire Road Charlottesville, VA 22902 Voice: (434) 296-58321Faz: (434) 972-4126
Revised 11 /l /2015 Page 2 of 3
W
Intake to complete the following:
Isl
Is us L1, HIor PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y l
Will be food preparation?
If so, give applicant a Health Department form.
Zoning review can not begin until we receive approval from Health
Dept, FAN DATE - _ ......... _....._-
Circle the one that applies
Is parcel on private well pu c wa
If private well, provide H ent form.
Zoning review can not begin until we receive approval from Health
Dept, FAX DATE
Circle the one that appli
Is parcel on septic or Me 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 =Inplete the following:
Reviewer to complete the following:
Square footage of use: - &0 o
2 1 N
Permitted as:'�
Under Section: &VA& 42K4
Supplementary regulations section:
Parking formula:
Required spaces:
ItemM be verified in the Meld:
Inspector : Date:
Notes:
Yiai ons:
Y/
if so, ist.
I'ro
YI��
If so, List;
...............
Variance:
& I N
If so, List:
SP's:
6)IN
If so, List;
7-
Clearances:
5D "is l
61 �-
Revised 111112015 Page 3 of 3
"�:RTIFICATION THAT .NOTICE OF THE
APPLICATION HAS BEEN PROVIDED TO THE LANDOWWE
Thfs form must amomrmy zoaing rrppllcw*w (home occupation, Zoning aearance, Zoning
A&fnfstratvr Determinagorts orAppeals, Sign Permtis, Bufidfng Perm&) if the application fs not the
owner.
I certify that notice of the application,
[County application name and number]
was provided to `li -%A ( the owner of record of Tax Map
(name(s) of the record owners of the parcel]
and Parcel Number Q S- 1 d LA 13 by delivering a copy of the application in the
manner identified below:
Hand delivering a copy of the application to
[Marne of the record owner ifthe record owner is a
person; if the owner of record is an entity, identify the recipient ofthe record and the recipient's
title or office for that entity]
on
bate
'✓ Mailing a copy of the application to � k( i L L�f l i
[Name of 1he reedid 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]
Ito the foi lowing address:
T.lt
f address; written notice mailed to the owner at the lait 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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