HomeMy WebLinkAboutCLE201600104 Application 2016-05-24Application for Zonin Clearance"•
F�
OFFIC SE ONLY
PLEASE REVIEW ALL 3 SHEETS Check # Date: a
Receipt # I Staff:
PARCEL INFORMATION
Tax Map and Parcel: a I r 1 , Existing Zonin
" go od
Parcel Owner• dl'
Parcel Address: 1600 _gj0 626a_ City 6aJsttd11g,le State VA Zip
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project? WP-1171.tv1 WLA
Address :l StmeAriS .' _ City EYti State -/A Zip 2-;L2
Office Phone: Cell # # E-mail'y/a-�3 @ i • ��j"t
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name V New business
Business Name/Type: 4JIa ' -e
Previous Business on this site 11 r
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: Ct r-• 3 t fn ntCq=R
*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 (Jfmj,, tjl. Printed—UPAjLtm 101A
AP OVAL INFORMATION
[proved as proposed [ ] Approved with conditions [ ] Denied
[ ] 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 ��{ �a.,
Zoning Official Date J
Otber Official Date
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (434) 972-4126
Revised 11/1/2015 Page 2 of 3
Intake to complete the following:
Y0
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y N
Will ere 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 or ie water? �
If private well, provide He ith � �ettt,I M.
Zoning review can not begi ntil we receive approval from Health
Dept. FAX DATE
Circle the one that Cpublic
Is parcel on septicsewer?
YIN
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y !i N
Wil ere 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: %
Y]/ N
Prmitted as: f�
Under Section:
Supplementary regulations section:
Parking formula:
Required spaces:
It/
ItemM be verified in the field:
Violations:
YIN
If so, List:
Proffers:
Y/N
If so, List:
Variance:
YIN
If so, List:
SP's:
YIN
If so, List:
Clearances:
SDP's
Revised 11/1/2015 Page 3 bf 3
CERTIFICATION THAT NOTICE OF THE
APPLICATION HAS BEEN PROVIDED TO THE LANDOWNER
Thal farm 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;
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 toe 64Ile n I me-, gehvr t�
[Name of the record owner if the record o ner is a person; manayQ11"
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— Y1—to the following address;
Date
[address; written notice wailed 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].
IMINS
Signature fApplicant
W Evijuyl V14 _
Print Applicant Name
4,11? It 6
Date
i