HomeMy WebLinkAboutCLE201600118 Application 2016-05-13Application for Zoning Clearance„
CLE #
05� �•�
O C USE ONLY
PLEASE REVIEW ALL 3 SHEETS Check # Date:
Receipt # Staff.•
PARCEL INFORMATION
Tax Map and Parcel: f _I IJ Existing Zoning�}�
Parcel Owner; k-A 1 q' up-W V _
Parcel Address:15, pCinta(0t5G_-nfCr City' rK U(9_State UF1 Zip
(include suite or floor)
PRIMARY CONTACT Who should we call/write concerning this project? KVt �_ 1f S4 Lums
Address: 1L02�3 Rio Vhk 19-r-X -3 ib I City Y-V 1 't;k%k%.te V F , Zip D,:,.L90 I
Office Phone: (� Cell # Dsf4# E-mail 4k _ ,3
APPLICANT INFORMATION
Check any that apply:^ Change of ownership Change of use Change of name New business
Business Name/Type:
Previous Business on this site=bS Ce - 60cfc? 12
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:
*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 best of my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature Printed `zlc ti'�- L `/V
is
APPROVAL INFORMATION
Approved as proposed [ ] Approved with conditions l j Demea
] 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:
Building Official �— Date 1!�_ It( I! (-
Zoning Official , Date
Other Official LI Date
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (434) 972-4126
Revised 11/1/2015 Page 2 of 3
Intake to complete the following:
Reviewer to complete the following:
Y / Square footage of Use: s,62 d
Is us ' LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet, / N
Qrmitted as:6 1
Y II
W re be food preparation? Under Section: ZS Z• [
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 applies
Is parcel on private well or ublic water
If private well, provide Hea ment form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applies
Is parcel on septic tf=D
-n.
YJ N
ill you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y 1
Wil re be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the following:
Parking formula:'
Required spaces: f�
YIN
Items to be verified in the field:
Inspector•
Notes:
Date:
Viol Yons•
Y/
If so, j j ist:
Proffers:
(0/N
If so, List:
2�
Variance:
In/ N
so, List:
SP's:
0I N
If so, List:
7
7— 9�
Clearances:
SDP's
Revised 11/1/2015 Page 3 bf 3
CERTIFICATION THAT NOTICE OF THE
APPLICATION HAS BEEN PROVIDED TO THE LANDOWNER
This farm must accompany zoning applications (Home Occupation, Zoning Clearance, Zoning
Administrator Determinations orAppeats, ,Sign Permits, Building Permits) if the application is not the
owner.
1 certify that notice of the application,
[County application name and number]
was provided to dK"I the owner of record of Tax Map
[name(s) of th cord owners of the parcel]
and Parcel Number
manner identified below:
X Hand delivering a copy of the application to
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__�G II(: I IZo
Dam
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].
Signature of Applica
FQ
1 'l
Print Applicant Nam
_ SDI � I l �
Dates, —