HomeMy WebLinkAboutCLE201600110 Application 2016-05-31Application for Zoning Clearance
CLE #.� / /I () r °,:.
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OFFICE USE ONLY
PLEASE REVIEW ALL 3 SHEETS Check # Date:
Receipt #-YZm 9 47 Staff-
PARCEL INFORMATION U
Tax Map and Parcel: _ II __ ___ `�� J U i _ Existing Zonin
Parcel Owner: �JJlywtw
Parcel Address: %f%,0,9&! City 41�1-r-S- 0- State
(include su'(a or floor)
PRIMARY CONTACT
Who should we call/write concerning this project?
Address: 9o259 eT; 444 44, City 41144//f State Zip D1'
Office Phone: Cell # A"6-67;Y Fax # E-mail i iAp/�a6�� xwl, c-
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name ALilew business
Business Name/Type: to y' at & ,
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: /99 I cSAsQ Cs�
AW,4 F
*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 lyve the owner's permission to use the space indicated on this application. I also certify that the information provided
is true and accurate 2b of y ow[e . I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature Printed �4414, 11�4
APPROVAL IIMRMATION
')4 Approved 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 I_ �_ C
Zoning Official Date f
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 I I/I/2015 Page 2 of
Intake to complete the following:
N
he'use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y /1
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 we
l ater?
If private well, provide ealth D ent form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that a ies
Is parcel on septic o ublic sewe
Y/N
Will you be putting up a new sign of any kind?
Sign permit.
Permit #
If so, obtain proper
YIN
Will 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:
I N
ermined as:
Under Section: { • Z a
Supplementary regulations section:
Parking formula: /�
Required spaces:
Y/
Items to be verified in the field:
Inspector • Date:
Notes:
Violations:
Y/
If so, ist:
Proffe :
Y/
If so, ist:
Varia ce:
Y/n
If so, ist:
91s:
IN
If so, List:
Clearances:
SDP's
Revised 11/1/2015 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,
was provided to
[County application name and number]
[name(s) of the record owners of the parcel]
the owner of record of Tax Map
and Parcel Number by delivering a copy of the application in the
manner identified below: .�/�
Hand delivering a copy of the application to - as- ;~ 4,1 ,ww
[Name of the record owner if the record er 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 S` 3
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].
"-404r
S ature of pplicantt�
Pik,( 4r�4G7
Print App9cant Name
Date